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Presented  by 
Walter  P.  Dresser,  D,  0. 


COLLEGE    OF    OSTEOPATHIC    PHYSICIANS      g 


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AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA      U 


Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/diseasesofchildrOOshefiala 


DISEASES  OF  CHILDREN 


; 


DISEASES  OF  CHILDREN 

DESIGNED  FOR  THE  USE  OF  STUDENTS 
AND    PRACTITIONERS    OF    MEDICINE 


HERMAN  B.  SHEFFIELD,  M.D. 


Formerly  Instructor  in  Diseases  of  Children,  New  York  Postgraduate  Medical  School 

and  Hospital,  and  Medical  Director,  Beth  David  Hospital,   Consulting 

Physician  to  the  Jewish  Home  for  Convalescents  and  the 

East  Side  Clinic  for  Children. 


WITH  238  ILLUSTRATIONS,  MOSTLY  ORIGINAL, 
AND  NINE  COLOR  PLATES 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1921 


VUSSLOQ 


Copyright,  1921,  By  C.  V,  MosnY  Company 

(.All  rights  reserved) 


Printed  in  the  U.   S.   A. 


Press  of 

C.   V.  Mosby  Comt'any 

St.  Louis,  U.  S.  A. 


TO  THE  MEMORY  OF  HIS   BELOVED  SON 

ROBERT  LEONTE 

THIS   VOLUME 

IS    AFFECTIONATELY   DEDICATED 

BY  THE  AUTHOR 


PREFACE 


This  volume  is  the  consummation  of  the  author's  experience  in  the 
field  of  pediatrics  for  nearly  thirty  years.  It  embodies  the  latest  knowl- 
edge of  the  theory  and  practice  of  the  diseases  of  infancy  and  childhood 
and  is  designed  to  meet  the  needs  especially  of  the  general  practitioner 
and  medical  student. 

The  book  is  conveniently  divided  into  fourteen  sections,  the  classifica- 
tion of  the  diseases  varying  somewhat  from  that  of  older  textbooks,  so 
as  to  correspond  to  the  modern  conception  of  the  causation  of  the  dis- 
eases in  question. 

Infant  feeding  is  based  upon  the  most  recent  studies  of  the  digestibil- 
ity of  proteins,  fats  and  carbohydrates  and  upon  the  author's  practical 
experience.  The  fads  and  fetichisms  of  the  erratic  reformer  and  senile 
reactionary  are  eliminated.  Breast  feeding  is  recommended  in  prefer- 
ence to  bottle  feeding,  yet  the  author  believes  that  hosts  of  perfectly 
healthy  babies  can  be  reared  on  cow's  milk,  if  good  judgment  is  applied 
in  the  selection  of  suitable  milk  mixtures.  A  mixed  diet  is  advocated  for 
infants  over  nine  months  of  age  and  well  tried  formulas  and  diet  lists 
are  appended  for  infants  and  older  children.  A  special  dietary  is  also 
provided  for  mentally  deficient  children. 

The  author  hopes  that  the  chapter  on  examination  of  the  patient  and 
semeiology  of  disease  will  greatly  aid  especially  the  beginner  to  surmount 
the  difficulties  of  diagnosis  in  infants  and  older  children.  The  normal 
anatomy  and  physiology  are  contrasted  with  the  abnormal.  Prominent 
symptoms  which  several  diseases  have  in  common  are  analyzed  in  rela- 
tion to  their  pathogenesis  and  the  different  methods  of  physical  diagnosis 
are  amply  elucidated  and  illustrated.  The  article  on  the  clinical  signifi- 
cance of  the  large  abdomen  may  prove  of  special  interest  to  the  reader. 

The  time  for  "snap  diagnoses"  is  past.  Every  obscure  fever  can  no 
longer  be  dubbed  malaria,  and  every  cold  bronchitis,  for  the  very  good 
reason  that  up-to-date  laymen  are  sufficiently  educated  to  demand  a 
more  exact  and  scientific  diagnosis.  To  meet  this  requirement,  a  careful 
survey  is-  presented  of  the  most  modern  methods  of  laboratory  diagnosis, 
such  as  the  Schick  test,  the  complement-fixation  reaction  of  tuberculosis, 
the  tuberculin  tests,  the  "Wassermann  reaction  of  syphilis,  the  Widal  re- 
action of  typhoid  fever  and  the  Weil-Felix  reaction  of  typhus  fever.  The 
therapeutic  value  and  the  indications  for  the  use  of  serums  and  vaccines 

7 

22901 


8  PREFACE 

are  fully  discussed  and  the  prophylactic  efficiency  of  diphtheria-toxin- 
antitoxin-immunization  is  dwelt  upon  at  length. 

A  mere  glance  at  the  chapter  on  materia  medica  will  assure  the  reader 
that  the  author  is  not  a  therapeutic  nihilist,  but  on  the  contrary,  a  firm 
believer  in  the  efficiency  of  some  drugs.  One  of  the  principal  reasons  for 
the  survival  of , many,  often  utterly  useless,  proprietaries  is  the  fact  that 
medical  students  receive  but  perfunctory  instruction  in  pharmacology 
and  prescription  writing,  and  often  do  not  even  appreciate  the  inertness 
and  incompatibilities  of  the  drugs  contained  in  the  concoctions.  The 
author  hopes  that  the  young  beginner  will  profit  by  memorizing  his  ar- 
ticle on  select  and  palatable  medication  and  by  making  use  of  some  of 
the  numerous  prescriptions  distributed  throughout  the  book.  Attention 
is  also  directed  to  the  instruction  given  in  hydrotherapy,  (which  includes 
hypodermoclysis,  saline,  intravenous,  intraperitoneal  and  intrasinus  in- 
jections) massage,  electricity,  climatology  and  organotherapy. 

To  obviate  the  great  loss  of  life  that  still  prevails  among  the  newborn, 
their  diseases,  and  more  especially  those  of  septic  nature,  are  gone  into 
minutely.  It  has  often  occurred  to  the  author  that  a  certain  number  of 
cases  of  dislocation  of  the  hip  in  infants  instead  of  being  congenital  in 
character  are  in  reality  acquired  as  a  result  of  sepsis,  and  he  hopes  that 
the  reader  will  henceforth  scrutinize  these  cases  with  greater  care  and 
possibly  confirm  the  author's  observations.  Under  the  head  of  ''Feeble 
Vitality"  are  grouped  the  diverse  diseased  conditions  in  which  feeble 
vitality  forms  the  predominating  feature.  Herein  are  included  also  the 
premature  babies  which  need  the  special  care  chiefly  to  overcome  their 
feeble  vitality. 

A  separate  chapter  is  also  reserved  for  the  numerous  congenital  mal- 
formations which  are  frequently  amenable  to  treatment  if  taken  in 
hand  early  and  treated  skillfiilly.  This  refers  especially  to  congenital 
pyloric  stenosis  which  is  fully  discussed  from  a  medical  as  well  as  surg- 
ical point  of  view.  A  great  many  illustrations  accompany  the  text  and 
should  prove  helpful  early  to  detect  the  divers  abnormalities. 

In  the  description  of  acute  gastroenteric  affections  the  classification  of 
Finkelstein  is  followed  with  but  slight  modifications.  As  the  great  ma- 
jority of  these  cases  are  the  result  of  milk  infection,  stress  is  put  chiefly 
upon  the  care  in  handling  the  milk  and  the  dietetic  changes  that  are 
indicated  in  individual  cases.  The  active  treatment  is  presented  briefly 
and  clearly  and  is  based  upon  the  author's  personal  experience.'  Faulty 
metabolism  is  treated  in  another  section  of  the  book,  in  which  are 
grouped  rachitis,  scorbutus,  acidosis,  exudative  diathesis,  glycosuria 
and  the  allied  affections.  Intussusception  and  appendicitis  are  dis- 
cussed as  strictly  surgical  diseases. 


PREFACE  9 

The  section  on  respiratory  diseases  includes  those  of  the  nose,  throat, 
and  ears.  The  importance  of  diseased  tonsils  and  adenoids  as  the  im- 
mediate cause  of  widespread  systemic  infections  is  given  due  prominence. 
Enucleation  of  the  tonsils  is  advocated  in  preference  to  tonsillotomy, 
which  latter  generally  fails  to  eradicate  the  source  of  the  trouhle.  On 
the  other  hand,  it  cannot  be  denied  that  tonsillectomy  is  a  rather  serious 
operation.  All  the  necessary  precautions  against  untoward  results  are 
amply  emphasized  when  speaking  of  the  dangers  of  the  operation.  The 
diagnosis  of  deafness  is  elaborated  with  greater  detail  than  in  other  text- 
books on  pediatrics;  the  different  tests  will  prove  useful  to  the  family 
physician  who  is  often  consulted  about  the  listlessness  and  inattentiveness 
of  some  of  his  little  patients.  In  the  description  of  the  diverse  inflam- 
mations of  the  lungs  and  pleura,  the  author  has  endeavored  to  embody 
the  very  latest  advances  in  serology  which  offer  the  only  hope  for  the 
ultimate  discovery  of  a  specific  against  pneumonia.  Influenza  pneu- 
monia is  described  in  connection  with  influenza.  The  newest  views  on 
the  etiology  of  asthma  are  given  due  consideration,  but  the  author  is 
inclined  to  the  belief  that  the  symptoms  arising  from  protein  sensitive- 
ness, anaphylactic  manifestations,  etc.,  are  entirely  distinct  from  those 
of  genuine  asthma,  and  transient  in  character,  irrespective  of  the  thera- 
peutic measures  employed. 

With  introduction  of  school  inspection  in  a  number  of  states  the  fact 
has  been  disclosed  that  heart  disease  in  children  is  by  far  more  common 
than  was  generally  supposed.  How  much  of  it  may  be  congenital  in 
character  is  difficult  to  judge  from  the  reports  at  hand.  In  the  section 
of  heart  disease,  both  the  congenital  and  acquired  forms  of  heart  disease 
are  fully  elucidated.  Rest  and  digitalis  are  still  urged  as  the  only  re- 
liable therapeutic  means  at  our  command  in  heart  disease,  more  espe- 
cially in  the  noncompensating  variety.  Unfortunately  few  children  can 
accommodate  themselves  to  a  regime  of  everlasting  rest.  The  benefits 
derived  from  graduated  exercises  in  heart  disease  of  children  which  are 
fully  delineated  in  this  chapter  are  as  yet  an  unknow^n  quantity,  yet 
worthy  of  trial.  The  author  has  failed  to  find  any  signal  diagnostic  help 
from  the  use  of  the  sphygmomanometer,  sphygmograph,  cardiograph, 
and  similar  apparatus,  hence  has  omitted  their  description. 

Except  for  the  recent  advances  in  the  study  of  blood  coagulation  prac- 
tically no  progress  has  been  made  in  the  knowledge  of  the  diverse  blood 
affection.  No  attempt  therefore  has  been  made  to  disrupt  the  generally 
accepted  classification  and  methods  of  treatment.  For  the  want  of  a 
better  term  hemorrhea  is  used  instead  of  hemophilia — which  latter  is  an 
utterly  inappropriate  designation  for  spontaneous  hemorrhage.  Trans- 
fusion is  recommended  as  the  most  reliable  remedy  to  control  this  kind 


10  PREFACE 

of  bleeding.  The  author  has  refrained  from  going  into  a  minute  de- 
scription of  the  pathology  of  blood  diseases,  since  excepting  Von 
Jaksch's  anemia,  which  is  peculiar  to  childhood,  they  are  fully  discussed 
in  text-books  on  general  medicine. 

To  a  great  extent  the  same  holds  true  of  kidney  diseases,  except  pye- 
litis, which  is  of  very  frequent  occurrence  in  children,  and  hence  is  re- 
ceiving careful  attention.  A  great  deal  is  yet  to  be  learned  about  the 
management  of  pyelitis.  Like  the  urinary  antiseptics  the  use  of  vac- 
cines and  kidney  flushing  have  thus  far  failed  in  the  majority  of  recal- 
citrant cases.  The  importance  of  early  diagnosis  and  prompt  treatment 
of  cervicitis  and  vulvovaginitis  is  strongly  emphasized  and  should  re- 
ceive due  consideration  on  the  part  of  the  general  practitioner  who  has 
ample  opportunities  to  observe  them. 

The  rather  frequent  association  of  acidosis  with  pyelitis  is  deserv- 
ing of  consideration  from  an  etiologic,  as  well  as  therapeutic,  point  of 
view. 

In  recent  years  the  profession  has  learned  to  appreciate  the  vital  role 
the  ductless  glands  are  playing  in  the  human  economy,  and  the  need 
for  further  scientific  investigation.  This  subject  therefore  is  treated 
broadly,  laying  particular  stress  upon  the  diseases  of  the  thyroid, 
thymus  and  pituitary  glands.  The  correlation  of  the  disturbed  functions 
of  these  glands  to  mental  deficiencies  is  emphasized  in  another  section 
of  the  book,  when  discussing  the  mental  affections  of  infants  and  older 
children.    A  separate  chapter  is  devoted  to  this  greatly  neglected  subject. 

The  diseases  of  the  lymphatics,  the  skin  and  bones  are  dwelt  upon  at 
length.  Attention  may  here  be  directed  to  the  article  on  malignant 
disease  in  children  which  is  often  overlooked  in  the  early  stages.  Several 
vivid  photographs  and  roentgenograms  illuminate  the  text. 

The  author  hopes  that  the  chapter  on  nervous  diseases  will  be  found 
especially  instructive.  The  brain  and  cord  have  ceased  to  be  organs  best 
let  alone,  and  the  progressive  surgeon  does  not  at  all  hesitate  to  operate 
on  the  brain  as  occasions  arise.  Emphasis  is  put  upon  the  advisability 
of  operating  upon  suitable  eases  of  cerebral  hemorrhage  in  the  newborn, 
spastic  cerebral  paralysis,  epilepsy,  etc.  Spasmophilia  and  hysteria  are 
elaborated  with  great  care.  In  order  to  facilitate  their  study  in  con- 
nection with  diseases  of  the  brain  as  a  whole,  meningitis,  poliomyelitis 
and  encephalitis  are  incorporated  in  this  chapter,  although  from  an 
etiologic  point  of  view  they  belong  in  the  section  of  contagious  diseases. 

Of  the  greatest  importance,  of  course,  to  the  general  practitioner  is  af 
thorough  acquaintance  with  the  communicable  diseases  of  childhood 
which  are  ever  rampant  and  creating  an  overabundance  of  misery  to  man- 
kind.   This  subject  is  treated  exhaustively,  and  includes  a  large  number 


PREFACE  11 

of  tropical  diseases  which  have  recently  invaded  our  shores.  A  special 
article  is  allotted  to  pertussis  in  the  newborn  infant.  Epidemic  in- 
fluenza in  all  its  phases  is  described  in  detail,  more  especially  its  patho- 
genesis and  serum  treatment.  The  same  applies  to  poliomyelitis  already 
spoken  of  which  is  clarified  by  a  large  number  of  original  illustrations. 
The  exanthemata  are  discussed  from  a  modern  point  of  view.  In  the 
article  on  tuberculosis  are  included  the  tuberculous  affections  of  the 
brain,  glands,  skin  and  bones.  Syphilis,  in  all  its  forms,  is  receiving  ex- 
l)licit  consideration.  As  already  stated,  the  diphtheria-toxin-antitoxin- 
immunization  and  the  diverse  laboratory  diagnostic  tests  are  discussed 
in  the  chapter  on  the  prevention  and  control  of  disease. 

In  closing  the  author  wishes  to  extend  his  gratitude  to  the  authors  and 
publishers  whose  literature  and  illustrations  have  aided  him  in  the 
preparation  of  the  book ;  and  he  is  particularly  grateful  to  his  pub- 
lishers for  their  liberal  suggestions  and  good  will. 

H.  B.  S. 

Nkw  York  City. 


CONTENTS 


CHAPTEB  I 

Prevention  and  Control  op  Disease 25 

Inherent  Strength,  25;  Power  of  Eesistance  and  Susceptibility,  26;  Nutri- 
tion, 26;  The  Digestibility  of  the  Proteins  of  Milk  and  Their  Role  in 
Infant  Nutrition,  26;  Physiology  and  Pathology  of  the  Digestion  of  the 
Carbohydrates  in  Infancy,  32;  Fat  Metabolism,  37;  Fat  Eetention  and 
Excretion  in  Relation  to  Diet,  38 ;  Fat  in  the  Stools  of  Breast  Fed  In- 
fants, 38;  Fat  in  the  Stools  of  Infants  Fed  on  Modifications  of  Cow's 
Milk,  39 ;  Fat  in  the  Stools  of  Children  on  a  Mixed  Diet,  39 ;  The  Diges- 
tion of  Some  Vegetable  Fats  by  Children  on  a  Mixed  Diet,  41 ;  Woman 's 
Milk  Feeding,  42;  Artificial  Feeding,  48;  Cow's  Milk  Feeding,  48;  Labo- 
ratory and  Home  Modification  of  Cow's  Milk,  51;  Indications  of  Faulty 
Assimilation  of  the  Food,  55;  Cow's  Milk  Substitutes,  56;  Weaning  the 
Baby  and  Its  Feeding  Thereafter,  59;  Hygiene  and  Sanitation,  64;  Gen- 
eral Care  of  the  Newborn  and  Older  Children,  64;  Immunization — 
Acquired  Immunity.  Biologic  Diagnosis  and  Therapeutics,  71;  Variola 
Vaccine,  72;  Vaccination,  72;  Antidiphtheritic  Serum,  75;  Diphtheria 
Toxin- Antitoxin  Immunization,  75 ;  The  Local  and  Constitutional  Reaction, 
76 ;  The  Immunization  Response  in  Susceptible  Children,  76 ;  The  Immuniz- 
ing Results,  76;  Antitetanic  Serum,  77;  Antimeningitis  Serum  (Flexner), 
78 ;  Bacterial  Vaccines,  81 ;  Tuberculin  Tests  and  Tuberculins,  82 ;  Comple- 
ment-Fixation Reaction  in  Tuberculosis,  84;  Serum  Diagnosis  of  Syphilis 
(Wassermann),  85;  Serum  Diagnosis  of  Typhoid,  86;  Weil-Felix  Reaction 
of  Typhus  Fever,  87;  Allergy  or  Food  Idiosyncrasy-Test,  87;  Materia 
Medica  and  Therapeutics,  88;  Hydrotherapy,  88;  The  Internal  Use  of 
Water,  92;  Electricity,  96;  Massage,  99;  Climatotherapy,  100;  Select 
Medication  in  Cliildren,  101;  Digestants,  103;  Tonics,  103;  Mineral  Acids, 
105;  Alteratives,  105;  Antipyretics  and  Antirheumatics,  106;  Hypnotics, 
Anodynes  and  Antispasmodics,  107;  Stimulants,  108;  Heart  Sedatives, 
109;  Emetics,  109;  Expectorants,  110;  Diuretics  and  Diaphoretics,  110; 
Laxatives  and  Purgatives,  111;  Intestinal  Astringents,  112;  Gastric  Seda- 
tives, 112;   Organotherapy,  113;  Vitamines,  114. 

CHAPTER  II 

Examination  of  the  Patient  and  Semeiology  of  Disease 115 

The  Head,  116;  The  Face,  118;  The  Eyes,  120;  The  Ears,  122;  The  Nose, 
122;  The  Lips,  123;  The  Oral  Cavity,  123;  The  Neck,  129;  The  Thorax, 
and  its  Contents,  129;  Auscultation  and  Percussion,  129;  The  Thorax, 
132;  The  Lungs,  133;  Cough,  138;  Sputum,  Expectoration,  138;  The 
Heart,  139;    The  Abdomen  and  Its  Contents,  146;   The  Diagnostic  Sig- 

12 


CONTENTS  13 

nificance  of  Chronic  Abdominal  Enlargement,  151;  Infants'  Stools,  15S; 
Principal  Abnormalities  of  Urine,  159;  The  Genitalia,  164;  The  Rectum, 
165;  The  A'ertcbral  Column,  165;  The  Extremities,  166;  Weight  and 
Length  of  Normal  Cliildren,  171. 

CHAPTER   III 

Congenital  Malformations 174 

Congenital  Malformations  of  the  Head,  174;  Cephalocele  (Hernia  of  the 
Brain),  Meningocele,  Encephalocele,  Encephalocystocele  or  Hydroceph- 
alocele,  174;  Congenital  Malformations  of  the  Face,  Including  those  of 
the  Palate,  Mouth,  Eyes,  Nose  and  Ears,  175;  Clefts  of  the  Face  and  Lips, 
175;  Cleft  Palate  (Palatum  Fissum,  Palatoschisis),  176;  Defects  of  the 
Mouth  and  Tongue,  177;  Malformations  of  the  Eyes,  177;  Malformations 
of  the  Nose,  179;  Malformations  of  the  Ears,  179;  Malformations  of 
Larynx  and  Trachea,  180;  Malformations  of  the  Neck,  180;  Malformations 
of  the  Thorax,  182;  Malformations  of  the  Alimentary  Tract,  183;  Con- 
genital Stenoses  and  Atresia;  of  the  Intestines,  183;  Congenital  Hyper- 
trophy and  Dilatation  of  the  Colon  (Megacolon  Congenitum,  Hirschsprung's 
Disease),  184;  Atresia  of  the  Rectum  and  Anus,  186;  Defects  of  the  Ab- 
dominal Parietes,  187;  Congenital  Umbilical  Hernia,  188;  Persistence  of 
the  Ductus  Omphalomesentericus,  190 ;  Urachus  Fistula,  191 ;  Malforma- 
tions of  the  Genitourinary  Organs,  Congenital  Abnormalities  of  the  Kid- 
neys, 192 ;  Malformations  of  the  Ureters,  192 ;  Malformations  of  the  Blad- 
der, 192 ;  Malformations  of  the  Urethra,  Prepuce,  Testicles,  and  Vagina., 
193;  Congenital  Phimosis,  193;  Cryptorchidism,  195;  Hydrocele,  195;  Con- 
genital Malformations  of  the  Vertebral  Column,  197;  Spina  Bifida  or 
Hernia  of  the  Cord,  197;  Congenital  Sacral  Tumors,  200;  Malformations 
of  the  Extremities  and  Hip,  201 ;  Luxatio  Coxae  Congenita,  201 ;  Talipes, 
202;  Congenital  Affections  of  the  Muscles  and  Bones,  204;  Amyatonia 
Congenita,  204 ;   Myotonia  Congenita,  205 ;   Osteogenesis  Imperfecta,  205. 

CHAPTER  IV 

Injuries  and  Diseases  of  the  Newborn 207 

Birth  Injuries,  207;  Superficial  Structures,  207;  Caput  Succedaneum,  207; 
Cephalhematoma,  207;  Hematoma  Sternocleidomastoidei,  208;  Deep  Struc- 
tures, 208 ;  Central  Birth  Paralysis,  208 ;  Cerebral  Hemorrhage  Apoplexia 
Neonatorum,  208;  Peripheral  Earth  Paralysis,  210;  Facial  Palsy,  210; 
Brachial  Paralysis — Obstetrical  Paralysis — Duchenne-Erb  Pai'alysis,  211 ; 
Diseases  of  the  Newborn,  213;  Feeble  Vitality  of  the  Newborn,  213; 
Asphyxia  Neonatorum,  213;  Atelectasis  Neonatorum,  213;  Vitia  Cordis, 
214;  Syphilis  Embryonalis  s.  Fetalis,  214;  Premature  Birth,  214;  Man- 
agement of  "Feeble  Vitality  of  the  Newborn"  with  Special  Reference 
to  the  Premature  Baby,  216;  Sclerema  Neonatorum,  218;  Scleredema 
Neonatorum,  218;  Sepsis  Neonatorum,  219;  Local  Sepsis,  219;  Omphalitis 
(Inflammation  of  the  Navel),  219;  Omphalorrhagia  (Bleeding  from  the 
Navel — Idiopathic  Umbilical  Hemorrhage),  222;  Umbilical  Granuloma 
(Excrescence,    Fungus,    Sarcomphalos,    222;    Ophthalmoblennorrhea    Neo- 


14  CONTENTS 

natorum  (Gonorrheal  or  Purulent  Ophthalmia,  222;  Pemphigus  Neona- 
torum, 224 ;  Dermatitis  Exfoliativa  Neonatorum,  225 ;  General  Sepsis, 
226;  Tetanus  (Trismus)  Neonatorum,  226;  Arteritis  and  Phlebitis  Um- 
biliealis,  228;  Erysipelas  Neonatorum,  229;  Helena  Neonatorum,  229; 
Epidemic  Hemoglobinuria  with  Icterus  in  the  Newborn,  229;  Acute  Fatty 
Degeneration  of  the  Newborn  (Buhl's  Disease),  230;  Functional  Dis- 
orders of  the  Newborn,  231 ;  Uric  Acid  Infarct,  231 ;  Icterus  Neonatorum 
Catarrhalis,  231 ;   Mastitis  Neonatorum,  232. 

CHAPTER  V 

Diseases  of  the  Alimentary  Tract 233 

Diseases  of  the  Mouth,  233;  Stomatitis,  233;  Dcntitio  Difficilis,  236;  Dis- 
eases of  the  Salivary  Glands,  237;  Salivation,  237;  Ranula,  237;  Second- 
ary Parotitis,  238;  Diseases  of  the  Tongue,  238;  Glossitis,  238;  Diseases 
of  the  Esophagus,  239;  Esophagitis,  239;  Diseases  of  the  Stomach  and 
Intestines,  241;  General  Etiology,  241;  Stenosis  Pylori  Congenita,  242; 
Acute  Gastroenteritis,  248;  Classification,  248;  Cholera  Infantum,  250; 
Subacute  and  Chronic  Gastroenterocolitis,  253;  Dysentery,  Enterocolitis, 
Ileocolitis,  257;  Acidosis,  257;  Proctitis,  257;  Colica  Infantum,  Gastralgia, 
Enteralgia,  Neuralgia  Enterica,  257;  Chronic  Constipation,  259;  Prolapsus 
Ani,  Prolapsus  Recti,  263;  Intussusception,  264;  Appendicitis,  Typhlitis, 
Perityphlitis,  269;  Peritonitis  Acuta,  275;  Intestinal  Worms,  276;  Anky- 
lostomiasis, Uncinariasis,  280 ;  Diseases  of  the  Liver,  283 ;  Icterus  Ca- 
tarrhalis, 283;  Diseases  of  the  Parenchyma  of  the  Liver,  283;  Cirrhosis 
of  the  Liver,  284;  Acute  Yellow  Atrophy,  285;  Fatty  Liver,  285;  Amy- 
loid Liver,  285;  Abscess  of  the  Liver,  285;  Tumors  of  the  Liver,  286. 

CHAPTER  VI 

Diseases  of  the  Respiratory  System 287 

General  Remarks,  287;  Diseases  of  the  Nose  and  Throat  and  Ear,  288; 
Rhinitis  Acuta,  288;  Rhinitis  Chronica,  289;  Epistaxis,  289;  Tumors  and 
Foreign  Bodies  in  the  Nose,  290 ;  Sinusitis,  291 ;  Pharyngitis  Acuta,  292 ; 
Pharyngitis  Chronica,  292;  Angina,  293;  Tonsillitis  Acuta,  Amygdalitis, 
Quinsy,  *293;  Hypertrophy  of  the  Tonsils,  296;  Adenoid  Vegetations, 
297;  Dangers  and  Accidents  Attending  Adenoid  and  Tonsil  Operations, 
300;  Retropharyngeal  Abscess,  301;  Otitis  Media,  303;  Deafness,  306; 
Interpretation  of  Tests  for  Hearing,  307;  Indications  of  Labyrinth  or 
Auditory  Nerve  Deafness,  308 ;  Laryngitis  Acuta,  308 ;  Laryngitis  Chronica, 
311 ;  Edema  Glottidis,  313 ;  Laryngeal  Tumors,  313 ;  Foreign  Bodies  in  the 
Larynx,  314;  Diseases  of  the  Bronchial  Tubes,  Lungs  and  Pleura,  314; 
Bronchitis  Acuta,  314;  Bronchitis  Chronica,  316;  Broncho  or  Lobular  Pneu- 
monia, 316;  Lobar  Pneumonia,  320;  Pleuritis,  327;  Dry  Pleurisy,  327; 
Pleurisy  with  Effusion,  328 ;  Serous  or  Serofibrinous  Pleurisy,  330 ;  Hemor- 
rhagic and  Tuberculous  Pleurisies,  330;  Purulent  Pleurisy  (Empyema, 
Pyothorax),  331;  Chylous  Pleuritis  (Chylothorax),  333;  Asthma,  337; 
Emphysema  Pulmonum,  339;  Bronchiectasis,  340;  Pulmonary  Gangrene, 
341;  Pneumothorax,  Hemopneumothorax,  Pyopneumothorax,  343;  Pneu- 
mohypoderma,  344. 


CONTENTS  15 

CHAPTER   VII 

Specific   Communicable  Disease 345 

Influenza,  340;  Vaccine  from  Influenza  Bacillus  as  a  Propliylaclic,  354; 
Vaccines  from  Streptococcus  and  Other  Organisms,  356;  The  Polyvalent 
Vaccine  of  Rosenow,  357;  Rubeola,  358;  Rubella,  363;  Diphtheria,  365; 
Differential  Diagnosis,  374;  Intubation  in  Laryngeal  Diphtheria,  376; 
Tracheotomy,  381 ;  Scarlatina,  382 ;  The  Fourth  Disease,  394 ;  Varicella, 
394;  Variola  Vera.  Varioloid,  395;  Typhus  Abdominalis,  399;  Typhus 
Exanthematicus,  404 ;  Typhus  Recurrens,  404 ;  Glandular  Fever,  405 ;  Ma- 
laria, 405;  Intermittent  Fever,  406;  Remittent  (Estivo-autumnal)  Fever, 
407;  Chronic  Malarial  Cachexia,  408;  Dengue,  410;  Rocky  Mountain  Fever, 
410;  Pestis  Americana,  411;  Ileocolitis  Epidemica,  412;  Rheumatismus 
Acutus,  414;  Differential  Diagnosis,  418;  Rheumatoid  Arthritis,  420; 
Still's  Disease,  422;  Rheumatisms  Nodosus  Infantilis,  422;  Erythema 
Nodosum,  424;  Poliosis  (Purpura)  Rheumatica,  424;  Myositis,  425; 
Polymyositis,  425;  Myositis,  Ossificans,  426;  Multiple  Exostoses, 
426;  Meningitis  Cerebrospinalis,  427;  Poliomyelitis  Anterior,  427;  En- 
cephalitis Lethargica,  427;  Parotitis  Epidemica,  427;  Pertussis,  429; 
Whooping  Cough  in  the  Newborn,  434;  Tuberculosis,  437;  Introductory 
Remarks,  437;  Miliary  Tuberculosis,  442;  Phthisis  Pulmonum,  444;  Tuber- 
culosis of  the  Brain,  452 ;  Tuberculosis  of  the  Abdominal  Organs,  453 ; 
Tuberculous  Peritonitis,  453;  Intestinal  Tuberculosis,  456;  Tuberculosis 
of  the  Genitourinary  Tract,  456;  Scrofulosis,  458;  Tuberculosis  of  the 
Bones  and  Joints,  461 ;  Tubercular  Osteomyelitis  and  Arthritis,  461 ; 
Tuberculosis  of  the  Vertebral  Column,  462 ;  Morbus  Coxarius,  466 ;  Knee- 
joint  Disease,  470;  Spina  Ventosa,  472;  Nontuberculous  Osteomyelitis, 
473;  Osteosarcoma,  476;  Scoliosis,  479;  Syphilis  Hereditaria  s.  Congenita, 
482;  SyjAilis  Embryonalis,  s.  Fetalis,  482;  Syphilis  Neonatorum,  483; 
Syphilis  Hereditaria  Tarda  s.  Lata,  490;  Acquired  Syphilis,  494;  Fram- 
besia,  496;   Leprosy,  497;  Pestis  Bubonica,  499. 

CHAPTER  VIII 
Disturbances  of  Metabolism 501 

Marasmus,  Athrepsia,  Infantile  Atrophy,  501;  Rachitis,  503;  Achondro- 
plasia, 512;  Scorbutus  Infantum,  514;  Beriberi,  517;  Pellagra,  517;  Dia- 
betes Mellitus,  518;  Diabetes  Insipidus,  520;  Adipositas,  520;  Exudative 
Diathesis,  521;  Acidosis,  522. 

CHAPTER  IX 

Diseases  of  the  Circulatory  System 525 

Congenital  Heart  Disease,  525;  Persistence  of  the  Foramen  Ovale,  526; 
Persistence  of  the  Ductus  Arteriosus  Botalli,  526;  Defects  in  the  Septum 
Ventriculorum,  527;  Congenital  Stenosis  of  the  Pulmonary  Artery,  527; 
Congenital  Stenosis  of  the  Tricuspid  Valve,  528;  Congenital  Stenosis  of 
the  Ostium  Atrioventriculare  Sinistrum,  528 ;  Dextrocardia,  529 ;  Acquired 
Heart  Disease,   529;    Myocarditis,   529;    Pericarditis,   530;    Endocarditis 


16  CONTENTS 

Acuta,  533;  Endocarditis  Chronica,  536;  Differential  Diagnosis,  539; 
Stage  of  Compensation,  540;  Formal  Gymnastics — Cardiac  Cases,  542; 
State  of  Failing  Compensation^  544. 

CHAPTEE  X 

Diseases  of  the  Blood  and  Ductless  Glands 546 

Diseases  of  the  Blood,  546;  Anemia  Simplex,  Chlorosis,  547;  Pseudoleu- 
kemia Infantum,  Splenica,  549;  Pseudoleukemia  Lymphatica,  550;  Leu- 
kemia, 550;  Pernicious  Anemia,  551;  Hemorrhea  Congenita,  552;  Hemor- 
rhea  Acquista,  553 ;  Differential  Diagnosis,  555 ;  Morbus  Addisonii,  556 ; 
Diseases  of  the  Spleen,  556;  Movable  Spleen,  556;  Acute  Splenitis,  557; 
Chronic  Inflammation  of  the  Spleen,  557;  Banti's  Disease,  557;  Primary 
Family  Splenomegaly  (Gaudier),  558;  Adenitis  and  Lymphadenitis,  559; 
Diseases  of  the  Thyroid  Gland,  561 ;  Thyroiditis,  561 ;  Goiter,  561 ;  Ex- 
ophthalmic Goiter,  563;  Cretinism,  563;  Diseases  of  the  Thymus  Gland, 
564;  Acute  Thymitis,  566;  Chronic  Thymitis,  567;  Disease  of  the  Pitui- 
tary Gland,  or  Hypophysis  Cerebri,  571 

CHAPTER  XI 

Diseases  of  the  Kidneys,  Bladder,  etc 572 

Nephritis  Acuta,  572;  Nephritis  Chronica,  577;  Nephrolithiasis,  578; 
Pyelitis,  Pyelonephritis,  Pyelonephrosis,  580;  Hemoglobinuria,  581;  Or- 
thotic, Lordotic,  Cyclic  or  Functional  Albuminuria,  582;  Tumors  of  the 
Kidney,  582;  Cystitis,  Colicystitis,  584;  Vesical  Calculi,  586;  Spasmus 
Vesicae,  Dysuria,  Ischuria,  586 ;  Enuresis,  587 ;  Vulvovaginitis,  589 ;  Mas- 
turbation, 593;  Menstruatio  Precox,  594;  Gangrene  of  the  Genitalia,  594. 

CHAPTER  XII 

Diseases  of  the  Nerve  System       596 

Organic  Diseases,  596;  Hydrocephalus,  Congenital  and  Acquired,  596; 
Anemia  of  the  Brain,  600 ;  Hyperemia  of  the  Brain,  601 ;  General  Remarks 
on  Cerebral  or  Central  Paralysis  and  Brain  Localization,  601 ;  Intracranial 
Hemorrhage,  603;  Embolism  of  the  Brain  Arteries,  604;  Sinus  Throm- 
bosis, 604;  Meningitis  Acuta,  605;  Meningitis  Cerebrospinalis,  605;  Men- 
ingococcic,  Pneumococcic,  Tuberculous,  Streptococcic,  etc..  Meningitis, 
605;  Differential  Diagnosis,  613;  Diplegia  Spastica  Infantilis,  615;  Hemi- 
plegia Spastica  Infantilis,  618;  Encephalitis,  620;  Brain  Abscess,  621; 
Lethargic  or  Epidemic  Encephalitis,  624 ;  Poliomyelitis  Anterior,  627 ; 
Tumors  of  the  Brain,  645 ;  Epilepsia,  649 ;  Migraine,  Hemicrania,  653 ; 
Pavor  Nocturnus,  654 ;  Syringomyelia,  654 ;  Spinal  Hemorrhage,  655 ; 
Spinal  Meningitis,  655;  Myelitis,  656;  Ataxia  Hereditaria  (Friedreich), 
Heredoatoxie  Cerebelleuse  (Marie),  657;  Disseminated  Sclerosis,  657; 
Hereditary  Progressive  Muscular  Atrophies,  658;  Spinal  Progressive  Mus- 
cular Atrophy,  658;  Neural  Progressive  Muscular  Atrophy,  658;  Myo- 
genic Progressive  Muscular  Atrophy,  659 ;  Lipodystropliia  Progressiva, 
661 ;   Tumors  of  the  Cord  and  Membranes,  662 ;  Peripheral  Facial  Paral- 


CONTENTS  17 

ysis,  663;  Hemiatropliia  Faciei,  665;  Polyneuritis,  665;  Functional  Dis- 
eases, 668;  Spasmophilia,  668;  Eclampsia  Infantum,  669;  Tetanism,  671; 
Tetany,  673;  Pseudotetanus  (Escherich),  676;  Spasmus  Glottidis,  677; 
Chorea  Vera,  678;  Habit  Spasm,  681;  Sjjasmus  Nutans,  682;  Hysteria, 
682;    Dystonia  Musculorum  Deformans,   688. 

CHAPTER  XIII 

Amentia 600 

Idiocy  and  the  Allied  Mental  Deficiencies,  690 ;  In  Infancy  and  Child- 
hood, 690 ;  Stigmata  of  Degeneration,  697 ;  Normal  Intelligence,  698 ; 
The  Abnormal  Baby,  701;  Mental  Tests,  705;  Classification,  706;  Micro- 
cephalus,  707;  Hydrocei^halus,  710;  Paralytic  Amentia,  712;  Amaurotic 
Family  Idiocy,  716;  Mongolism,  718;  Cretinism,  Myxidiocy,  721;  Infan- 
tilism, 726;  Moramentia,  728;  Prophylaxis,  732;  Active  Treatment,  737; 
Hygiene,  737;  "Incentive"  Training  and  Physical  Therapeutic  Measures, 
739 ;  Medicinal  Treatment,  746 ;  Surgical  Treatment,  749 ;  Prognosis,  750 ; 
Amentia  in  Older  Children,  751 ;  Epileptic  Idiocy,  751 ;  Imbecility,  752 ; 
Mental  Affections  in  Older  ChildreUj  757;  Dementia,  757;  Dementia  Pre- 
cox, Katatonia,  Hebephrenia,  757;  Dementia  Paralytica,  759;  Melancholia, 
759;   Mania,  759. 

CHAPTER   XIV 

Diseases  of  the  Skin 761 

Eczema,  761 ;  Urticaria,  764 ;  Intertrigo,  765 ;  Psoriasis,  766 ;  Herpes  zos- 
ter, 767;  Miliaria,  Lichen  Strophulus,  768;  Ecthyma,  768;  Impetigo  Con- 
tagiosa, 769;  Pediculosis  Capitis,  770;  Pediculosis  Corporis,  771;  Pedicu- 
losis Pubis,  771;  Scabies,  771;  Tinea  Trichophytina  Capitis,  774;  Tinea 
Trichophytina  Corporis,  776 ;  Molluscum  Contagiosum,  776 ;  Telangiectases, 
Nevi  and  Angiomas,  777;  Combustio,  778;  Congela.tio,  779. 


COLOR  PLATES 


PLATE  PAGE 

I.  The  normal  stool  of  the  breast-fed  infant 42 

II.  Formed  alkaline  stools 54 

III.  Stomatitis  aphthosa   (advanced  stage)        234 

IV.  The   green,   acid   stool   of   dyspepsia 250 

V.  Angina  follicularis.     Angina  herpetiformis,  after  vesicles  burst.  Angina 

ulcerosa   (Vincentii) 292 

VI.  Buccal  exanthema  in  measles    (Koplik's  spots) 360 

VII.  Tonsillar  diphtheria 366 

VIII.  Angina  scarlatinosa  and  "strawberry  tongue" 384 

IX.  Life-cycle   of  Plasmodium   vivax        406 


ILLUSTRATIONS 


FIG.                                                                                                          ,  PAGE 

1.  Microscopic  appearances  of  woman's  milk 42 

2.  Breast   pumps       44 

3.  Holt's  milk  testing  apparatus 45 

4.  Chapin's   dipper   for  removal   of   "top-milk"        50 

5.  Stages  in  Widal  reaction  of  typhoid 86 

6.  Hydrocephalus 117 

7.  Fontanels 118 

8.  Diagram    of   the   visual   tract        121 

9.  Temporary  and  permanent  teeth 125 

10.  Ulcerative  stomatitis  involving  also  the  lips  and  adjacent  structures     .     .     .  127 

11.  The  thoracic  and  abdominal  regions 130 

12.  The  regions  of  the  back 131 

13.  Diagnostic  lines  of  the  thorax 135 

14.  Anterior  boundaries  of  the  lungs 135 

15.  Posterior  boundaries  of  the  lungs 135 

16.  Normal  heart  of  a  child  three  years  old 140 

17.  Normal  heart  of  a  child  eight  years  old 141 

18.  The  relative  and  absolute  heart  dulness  up  to  four  j^ears 142 

19.  The  relative  and  absolute  heart  dulness  up  to  eight  years 142 

20.  The  relative  and  absolute  heart  dulness  up  to  twelve  years 142 

21.  Topography  of  cardiac  valves 144 

22.  The  thoracic  and  abdominal  regions 146 

23.  Dissection   of   still-born   child        148 

24.  Topography  of  the  liver  and  spleen 149 

25.  Topography  of  kidneys,  spleen,  and  liver 150 

26.  Sarcoma  of  the  left  kidney 153 

27.  High  degree  of  rachitis.    Abdominal  enlargement  chiefly  in  epigastric  region  154 

28.  Tuberculous   peritonitis.      Abdominal    enlargement   most   marked    in   hypo- 

gastric  region 155 

29.  Buffalo    scale 172 

30.  Normal   infant's   weight   chart 172 

31.  Harelip 176 

32.  Bilateral  congenital  anophthalmia 178 

33.  Large  asymmetrical  cervical  ribs;  neuritis  and  vascular  disturbances  in  the 

right  arm 182 

34.  Moderate  degree  of  megacolon  congenitum  or  Hirschsprung's  disease,  in  a 

child  three  years  old 184 

35.  Congenital  absence  of  anus  and  rectum  and  of  scrotum  and  its  contents     .  185 

36.  Stomach  and  intestines  of  case  shown  in  Fig.  35,  showing  ending  of  colon 

in  a  blind  pouch   filled  with  meconium 186 

37.  Diastasis  recti  abdominis  in  an  amaurotic  idiot 187 

18 


ILLUSTRATIONS  19 

FIG.  P-^GE 

38.  Congenital  umbilical  hernia 188 

39.  Congenital    femoral    hernia 189 

40.  Ectopia  viscerum 189 

41.  Tlioracoabdominopagus  with  prolapse  of  intestines 189 

42.  Skiagram  of  thoracoabdominopagus.      (Same  as  Fig.   41.) 190 

43.  Congenital  hydrocele  communicans 196 

44.  Myelocystocele 198 

45.  Spina  bifida  occulta  in  a  boy  eight  years  old.     This  condition  Avas  associated 

with  incontinence  of  urine 199 

46.  Bilateral  club  feet  in  father  and  three  children 202 

47.  Same  case  as  Fig.  44  showing  also  congenital  club  foot 203 

48.  Osteogenesis   Imperfecta 205 

49.  Method  of  insertion  of  trocar  through  the  anterior  fontanel  to  reach  the 

ventricles 209 

50.  Obstetric  facial  paralysis  in  boy  fifteen  months  old,  which  failed  to  yield 

to  treatment 210 

51.  Bilateral  obstetric   brachial   paralysis,   the   so-called   "  Duchenne-Erb   Par- 

alysis"       211 

52.  Obstetric  brachial  palsy :     Erb  's  ' '  upper  arm  type ; ' '  failed  to  resi^ond  to 

treatment 212 

53  Incubator  room  for  newly  born  babies  with  feeble  vitality     ......  216 

54.  Breck's  feeder -    ...  217 

55.  Absorption  of  left  head  of  femur  and  consequent  dislocation  of  the  hip  in 

a  child  two  years  old  as  a  direct  result  of  sepsis  neonatorum  which  be- 
gan with  an  infection  in  the  navel 220 

56.  High  degree  of  "tetanism"  greatly  resembling  tetanus  neonatorum.     Note 

Fig.  59,  showing  same  case  during  partial  relaxation  of  the  spasm     .  227 

57.  Penny  in  esophagus  of  an  infant  readily  extracted  under  the  guidance  of 

the  roentgen   ray 239 

58.  Pylorus  stenosis  in  a  boy  three  months  old 243 

59.  Chronic  gastroenteritis  in  an  infant  ten  weeks  old 254 

60.  Prolapsus   recti 263 

61.  Stick  pin  in  transverse  colon  giving  rise  to   symptoms  of  intussusception 

requiring   operation 266 

62.  Oxyuris  vermicularis.     Female  and  male 277 

63.  Ascaris  lumbricoides 277 

64.  Tenia   saginata 277 

65.  Tenia   solium 278 

66.  Bothriocephalus    latus 278 

67.  Ankylostomum  duodenale 281 

68.  Uncinaria    Americana 281 

69.  Toy  ring  in  antral  cavity  giving  rise  to  empyema  of  the  antrum  of  High- 

more  in  a  child  three  years  old 291 

70.  Adenoids  in  a  boy  eleven  years  old.    Note  characteristic  dull,  facial  features 

and    contracted    chest        297 

71.  Spinal  curvature    (stooping)    secondary  to  adenoids 298 


20  ILLUSTRATIONS 

FIG.  PAGE 

72.  Ectropliaryngeal    alisccss    in    a    ten-month-ol<1    infant.     Note    characteristic 

attitude  of  nioutli.  head  and  neck 302 

73.  Fever  curve  of  typical  lo])ar  pneumonia  in  a  cliild  fourteen  months  old,  end- 

ing  by   crisis 322 

74.  Fever  curve  of  a  fatal  case  of  apex  pneumonia  with  marked  cerebral  symp- 

toms in  a   child  two  years   old 322 

75.  Grocco's  sign  of  jsleurisy  with  effusion   (paravertebral  triangle  of  dulncss 

on  the  side  opposite  to  that  of  the  effusion — G) 329 

76.  Extensive  right  empyema  in  a  child  four  years  old 332 

77.  Same  case  as  Fig.  76  three  weeks  after  resection  of  second  and  third  ribs. 

Note   clearing  of  right  lung 33o 

78.  Same  case  as   Fig.    76  two  months  later.     Right   lung   field   almost   clear. 

Note  retraction  of  chest  wall  and  secondary  scoliosis 336 

79.  Pneumothorax   (posterior  view).     Note  compression  of  lungs  and  disloca- 

tion  of  heart        341 

80.  Pneumohypoderma  (emphysema  cutis)   in  a  girl  five  years  old  complicating 

measles   with   pneumonia        342 

81.  Same  case  as  Fig.  80  six  weeks  later 343 

82.  Section  of  lung  of  epidemic  influenza  in  a  young  infant  showing  congestion 

of  the  blood  vessels  in  the  pleura  and  hemorrhages  just  beneath  the 
pleural  surface     346 

83.  Section  of  lung  of  epidemic  influenza  in  a  young  infant  showing  suppurative 

bronchitis  and  areas  of  pneumonia  about  the  bronchi 348 

84.  Fever  curve  of  atypical  influenza  in  a  baby  fourteen  months  old     .     .     .     350 

85.  Paralysis  of  N.  abducens,  with  convergent  strabismus  and  facial  paralysis 

following  postinfluenzal  encephalitis.     Her  mentality  remained  greatly 

affected 351 

86.  Fever  curve   of   measles       359 

87.  Fever  curve  of  German  measles 363 

88.  Instruments  for  intubation 378 

89.  Mode  of  feeding  after  intubation 379 

90.  Tracheotomy  tube        382 

91.  Fever  curve  of  a  case  of  scarlet  fever 385 

92.  Fever  curve  of  typhoid  fever  in  child  four  years  old 400 

93.  Rheumatic  torticollis   of  several  weeks '  duration  in  a  child   six  years  old 

which  greatly  resembled  cervical  spondylitis 417 

94.  Still's  disease  in  a  boy  five  years  old,  showing  the  arthritis  being  multiple     .     423 

95.  Still's  disease  in  a  boy  five  years  old.     Periarticular  changes  in  the  left 

wrist  joint       423 

96.  Still 's  disease  in  a.  boy  five  years  old.    Symmetrical  changes  in  the  periartic- 

ular soft  parts  of  the  knees  and  ankles 423 

97.  Multiple    exostoses        427 

98.  Epidemic  mumps 428 

99-103.  Breathing  exercise 439 

104.  Acute  pulmonary  miliary  tuberculosis   (cut  surface  of  the  lung)     .     .     .     442 

105.  Miliary  tuberculosis  of  the  lungs  in  a  child  nine  years  old 443 


ILLUSTRATIONS  21 
PIG.                                                                                                                                                                                               PAGE 

106.  Tuberculosis.      Horizontal   section  through   the  tuberculous  lower   lobe   of 

the  right  lung  of  a  two-year-old  child 44-5 

107.  Phthisis  pulmonum  in  a  child  twenty  months  old 447 

108.  A  group  of  tuberculous  patients  in  the  outdoor  "Shack"  of  the  Hospital 

for  Crippled  and  Deformed  Childrep,  New  York 450 

109.  Tuberculosis  of  the  brain    (boy  four  years   old) 452 

110.  Tuberculous  peritonitis  in  a  baby  fifteen  months   old;   she  has  fully   re- 

covered after  laparotomy 454 

111.  Characteristic  early  tubercular  infiltration  of  bladder,  as  seen  through  the 

cystoscope ;     .     .  457 

112.  A  large  tubercular  ulcer  below  the  orifice  of  the  right  ureter 457 

113.  Cystoscopic  view  of  the  base  of  the  bladder  in  a  case  of  tuberculosis  of 

the   left   kidney         457 

114.  Tuberculous  axillary   lymphadenitis         459 

115.  Tuberculosis  of  elbow  joint  in  a  boy  eighteen  months  old.     Note  discharg- 

ing   sinus          461 

116.  Pott's    disease        463 

117.  Rigidity  of  neck  associated  with  "cervical  ribs" 464 

118.  Same  case  as  in  Fig.  117  showing  peculiar  attitude  of  head  which  led 

to  the   erroneous   diagnosis       464 

119.  Advanced  dorsal  spondylitis  with  gibbus 465 

120.  Tuberculous   coxitis,   advanced   stage        467 

121.  Early  stage  of  hip-joint   disease 468 

122.  Hip-joint    disease 469 

123.  Tuberculosis  of  the  knee  in  a  thirteen-month-old  infant  who  a  few  months 

later  succumbed  to  tuberculous  pyothorax 471 

124.  Spina    ventosa 473 

125.  Osteosarcoma  of  the  head  and  upper  third  of  shaft  of  humerus  in  a  boy 

ten   years    old 476 

126.  Enchondroma  of  upper  third  of  humerus  in  a  child  eleven  years  old     .     .  477 

127.  Bone  cyst  in  shaft  of  humerus  causing  fracture  in  a  child  six  years  old     .  478 

128.  Sarcoma  of  the  left  femur  in  a  girl  eight  years  old 479 

129.  Lateral   spinal   curvature;    second   degree ' 480 

130.  Lateral  spinal  curvature,  S-shaped  scoliosis 481 

131.  Congenital  syphilis,   baby   three   weeks  old 483 

132.  Syphilitic  pemphigus,  especially  marked  on  the  soles  of  the  feet     .     .     .  484 

133.  Congenital  syphilis  in  an  eight-week-old  baby 485 

134.  Congenital  syphilis  in  a  six-week-old  baby 486 

135.  Syphilitic  dactylitis  of  right  index  finger  in  a  child  two  years  old     .     .     .  487 

136.  Periosteal  syphilis  of  left  ulna  in  a  child  ten  years  old 488 

137.  Syphilitic   baby   eleven   months   old 489 

138.  Syphilitic  "  Hutchinson  teeth  " 491 

139.  Gumma  of  the  right  parietal  bone  in  an  eight-year-old  boy  suffering  from 

syphilis   hereditaria   tarda 492 

140.  Syphilitic  osteoperiostitis  of  the  tibiae,  "Saber-shape-deformity"   and  of 

the  nasal  bones,  with  high  degree  of  rachitis 493 

141.  Case  of  leprosy  in  a  child  showing  infiltration  especially  in  ears,  lips  and 

hands 498 


22  ILLUSTRATIONS 

FIG.  PAGE 

142.  Marasmus  in  a  child  ten  months  old         502 

143.  Rachitic  "frons  quadrata"   in  an  infant  thirteen  moutlis  old     ....  504 

144.  Rachitic  beading  of  the  ribs,  "pot-belly,"  and  bow-legs 505 

145.  High  degree  of  rachitic  spinal  curvature 506 

146.  Rachitic  bow-legs,  "jug"   shaped  abdomen  and  sei)aration   of   epiphyses 

"double- jointed" 507 

147.  Rachitic  knock-knee  in  girl  six  years  old 509 

148.  Achondroplasia  in  a  ten-month-old  baby 512 

149.  Achondroplasia 513 

150.  Scorbutus  in  a  fifteen-month-old  infant 515 

151.  Adipositas;  child  weighs  thirty-six  pounds  at  eight  months 521 

152.  Vitium    cordis 525 

153.  Dextrocardia  in  a  girl  six  years  old.     Posterior  view 529 

154.  Fever  curve  of  malignant  endocarditis  in  a  child  three  years  ohl     .     .     .  534 

155.  Intense  dilatation  of  the  heart  in  a  two-month-old  infant  suffering  from 

congenital  heart  disease  which  was  greatly  aggravated  by  an  attack 

of  whooping  cough 537 

156.  Splenomegaly  in  association  with  von  Jaksch  anemia 549 

157  and  158.  Primary  family  splenohepatomegaly,  Gaucher  type,  in  brother  and 

sister 558 

159  and  160.  Distribution  of  the  principal  lymphatic  glands  of  the  neck  and 

trunk         560 

161.  Goiter   in   girl   eleven  years   old 562 

162.  Hypothyroidism — Myxidiocy,  in  a  girl  sixteen  years  old 563 

163.  Large  thymus 564 

164.  Precocious  child  eight  years  old;    began  to   menstruate  when  about  five 

years  old   (hyperpituitaria?) 570 

165.  Acute  nephritis  with  general  anasarca  in  a  four-month-old  infant     .     .     .  573 

166.  Same  case  as  Fig.  165  three  weeks  later 573 

167.  Oval  calculus  in  left  ureter  and  one  just  emerging  from  lower  pole  of  left 

kidney  in  a  child  nine  years  old 579 

168.  Adenosarcoma  of  right  kidney  in  a  boy  twenty-seven  months  old,  occupying 

almost  the  entire  abdomen 583 

169.  Congenital  hydrocephalus 596 

170.  Congenital  hydrocephalus  with  spina  bifida 597 

171.  Same  case  as  Fig.  170  showing  distended  spina  bifida  before  escape  of 

the  spinal  fluid 597 

172.  Hydrocephalus  following  meningitis 598 

173.  Acquired  acute  hydrocephalus,  following  acute  gastroenteritis  and  compli- 

cating rachitis 599 

174.  Epidemic  cerebrospinal  meningitis 607 

175.  Lumbar  puncture 610 

176.  Fever  curve  of  tuberculous  meningitis  in  a  child  two  years  old     ....  612 

177.  Diplegia  spastica  infantilis  in  a  baby  eight  months  old  who  sustained  cere- 

bral injuries   (with  hemorrhages)   during  obstetric  delivery     ....  616 

178.  Little's  disease.     "Scissors-Gait"  or  cross-legged  progression     ....  616 

179.  Diplegia  spastica  infantilis   (Little's  disease) 617 


ILLUSTRATIONS  23 

PIG.  PAGE 

180.  Hemiplegia  spastica  infantilis,  by  some  authors  looked  upon  as  a  "cere- 

bral" or  "  encephalitic "  type  of  poliomyelitis  with  lesions  chiefly  in 

the  motor  area  of  the  cerebral  cortex 619 

181.  Left  hemiplegia  following  acute  encephalitis 620 

182.  Poliomyelitis  "spinal  type;"  lesion  in  luml)ar  enlargement;  atrophy  and 

right  "  drop-foot " 633 

183.  Poliomyelitis  "spinal"  type;  lesion  in  cervical  enlargement;  paralysis  of 

upper  arm  as  well  as  right  serratus  magnus,  "angel  wing"  deformity 

of  right  scapula,  marked  muscular  atrophy 633 

184.  Poliomyelitis  "spinal  type;"  lesion  in  cervical  and  dorsal  regions;  partial 

paralysis    of    the    muscles    of    the    neck,    abdomen,    and    right    thigh 

(atrophy) 634 

185.  Poliomyelitis  "spinal  type;"  lesion  in  cervical  enlargement;  "neck  drop"  634 

186.  Poliomyelitis  affecting  the  abdominal  muscles  giving  rise  to  "ballooning" 

of  the  abdomen 635 

187.  Poliomyelitis   "bulbospinal  type;"   lesion   in   medulla;    paralysis   of   left 

facial  nerve,  left  forearm  and  left  leg 635 

188.  Poliomyelitis  ^'pontine"   or   "cerebral"   type;   lesions  in   pons,  medulla, 

and  spinal  cord;  paralysis  of  right  facial  nerve,  left  forearm  and  hand, 

external  respiratory,  and  abdominal  muscles  and  right  leg     ....  636 

189.  Same  case  as  Fig.  188  showing  also  high  degree  of  scoliosis 637 

190.  Secondary  passive  hydrocephalus  in  tumor   of  the  brain 645 

191.  192,    and    193.  Pseudohypertrophic    paralysis.      Demonstration    of    rising 

from  the  floor  by  ' '  climbing  upon  himself " 660 

194.  Peripheral  facial  palsy — Bell's  palsy 663 

195.  Nuclear  facial  palsy.     Eye  muscles  are  unaffected;   paralysis  limited  to 

lower  part  of  face 664 

196.  Diphtheritic  polyneuritis  in  a  boy  four  years  old 666 

197.  Same  case  as  Fig.  196  two  weeks  later 666 

198.  Same  case  as  Fig.  196  six  weeks  later 667 

199.  Tetanism  during  acme  of  spasm.     Note  characteristic  position  of  the  ex- 

tremities       671 

200.  Tetanism.    Same  case  as  Fig.  199  during  partial  relaxation  of  spasm     .     .  671 

201.  Same  case  as  Fig.  199  three  months  later 672 

202.  Tetany  in  a  child  eleven  months  old 674 

203.  Pseudotetanus 676 

204.  Hysterical  phantom  tumor  of  the  abdomen 684 

205.  Progressive  torsion  spasm 688 

206.  Microcephalitic   idiot 702 

207.  Amaurotic  idiot 702 

208.  Microcephalus — miniature  brain 707 

209.  Microcephalus — brain  degeneration 708 

210.  Hydrocephalic  idiot 710 

211.  Paralytic  idiot  of  antenatal  origin 714 

212.  Paralytic  amentia  in  consequence   of  cerebral  hemorrhage  during  instru- 

mental delivery 715 

213.  Amaurotic  family  idiocy  in  baby  14  months  old .  717 


24  ILLUSTRATIONS 

FIG.  PAGE 

214.  Macular  change  (cherry-rod  discoloration)  in  amaurotic  family  idiocy     .     .  717 

215.  Mongolian  idiot   of   23  months,   Calmuck  type 720 

216.  Cretin  from  birth;  total  idiot.     Note  "trident  hand" 722 

217.  Normal   at    one   year 723 

218.  Same  case  as  Fig.  217  pronounced  cretin  at  eight  years 723 

219.  Same  case  as  Fig.  218  four  weeks  after  treatment  with  thyroid     ....  724 

220.  Same  case  as  Fig.  218  ten  weeks  after  treatment  with  thyroid 725 

221.  Infantilism,  Brissaud  type,  six  years  old;  measures  32  inches  in  length     .  727 

222.  Infantilism,  typus  Lorain,  four  and  one-half  years  old;  measures  32  inches 

in  height  and  weighs  28  pounds,  acts  like  a  two-year-old  infant     .     .  727 

223.  Wrist  of  ament  10  years  old;  wrist  of  normal  child  six  years  old.     Note 

greater   number   of   carpi   in   the   latter 728 

224.  Moramentia  in  a  two-year-old  boy,  as  a  result  of  marked  adenoids  with  its 

consequences,  especially  difficult  hearing 729 

225.  Moramentia,  as  a  result  of  isolation  and  faulty  environmenjt 731 

226.  Feeblemindedness  in   a   boy   eight   years   old  following  an  attack   of   en- 

cephalitis: he  is  suffering  also  from  slight  left  hemiplegia     ....  752 

227.  Dementia  precox  in  a  girl  thirteen  years  old.    Note  also  cystic  degeneration 

of  the  thyroid  gland 757 

228.  Seborrheic  eczema  of  head  and  face 761 

229.  Psoriasis  in  a  girl  seven  years  old 766 

230.  Herpes  zoster 767 

231.  Impetigo  contagiosa  of  an  unusually  severe  type 769 

232.  Pediculosis  capitis,  showing  ova  on  hairs 770 

233.  Animal  parasites 772 

234.  Scabies,  in  an  infant 773 

235.  Trichophyton  tonsurans — threads  and  chains  of  si)ores  x400 774 

236.  Large-spored  ectothrix  ringworm  of  scalp 774 

237.  Tinea  tonsurans 775 

238.  Vascular  nsevus 777 


DISEASES  OF  CHILDREN 


CHAPTER  I 

PREVENTION  AND  CONTROL  OF  DISEASE 

Nutrition  and  Infant  Feeding.     Hygiene  and  Sanitation,     Immuni- 
zation.    Therapy 

The  warfare  ])etweeii  health  and  disease  evolves  with  the  earliest 
inception  of  life  of  the  organism.  The  battle  is  fiercely  rampant  and 
everlasting,  the  victory  at  best  but  temporary.  Supremacy  of  health 
over  disease  fluctuates  with  the  amount  of  inherent  strength  of  the 
individual,  the  natural  and  acquired  power  of  resistance,  and  the  as- 
sistance received  through  prophylaxis  and  therapeusis. 

Nature  aims  to  exterminate  the  weak,  and  right  at  birth  tests  the 
vitality  of  the  infant  in  a  manner  most  hazardous  to  its  subsistence. 
Thus,  accustomed  to  the  ideal  domicile  of  the  maternal  uterus — ^pro- 
tected from  traumatism  and  atmospheric  vicissitudes,  nurtured  with- 
out effort  and  animated  without  the  touches  of  pain  or  distress — the 
newborn  is  suddenly  east  upon  its  own  resources  into  a  sphere  of 
eternal  strife,  where  every  organism,  every  element,  is  struggling  for 
supremacy,  and  where  the  strongest — not  invariably  the  fittest — 
triumphs. 

Inherent  Strength 

Inherent  strength  is  essential  to  active  life,  to  maintenance  of  per- 
fect health.  A  powerful  constitution  will  overcome  an  attack  of  dis- 
ease that  will  fell  the  weak  and  the  frail,  A  strong  organization  will 
surmount  hardships  and  rapidly  recuperate  after  protracted  illness. 
Inherent  strength  is  not  procurable  after  birth.  It  is  a  consummation, 
an  inheritance,  of  ancestral  virility  and  vigor,  premarital  purity,  con- 
jugal devotion,  matrimonial  chastity,  sobriety  and  ideal  hygiene.  It 
can  be  fostered  by  regulation  of  marriage,  conservative  mutual  selec- 
tion, prohibition  of  consanguineous  marriages  and  those  encumbered 
by  grave  disease,  habits,  alcoholism  and  drug  addictions,  or  extreme 
poverty.  Finally,  it  can  be  greatly  improved  by  judicious  management 
of  pregnancy. 

25 


26  DISEASES   OF    CHILDREN 

Power  of  Resistance  and  Susceptibility 

Immunity,  protection,  or  power  of  resistance  against  disease,  and 
to  a  slighter  extent  also  susceptibility  toward  disease,  may  be  natural 
or  acquired.  It  varies  in  different  individuals  and  in  the  same  indi- 
vidual at  different  periods  of  life.  Natural  or  congenital  immunity  is 
aptly  exemplified  by  the  comparatively  rare  occurrence  of  communi- 
cable diseases  in  infants  under  three  months  of  age.  Congenital  sus- 
ceptibility is  demonstrable  by  the  prevalence  of  certain  affections  in 
some  families  or  races,  e.  g.,  hemophilia,  tuberculosis,  amaurotic  fam- 
ily idiocy  and  the  like.  In  contrast  to  inherent  vitality,  acquired  power 
of  resistance  is  vastly  influenced  during  the  life  of  the  child.  Thus, 
immunity  against  communicable  diseases  is  often  temporarily  or  per- 
manently conferred,  naturally  by  a  previous  attack  of  the  same  malady 
{e.g.,  yellow  fever,  pertussis),  and  artificially  by:  I.  Suitable  nutrition. 
II.  Hygiene  and  sanitation.  III.  Immunization.  IV.  Drugs  and  physi- 
cal therapeutic  measures. 

I.  NUTRITION 

Suitable  nutrition  is  indispensable  to  the  life  and  growth  of  the  in- 
dividual and  to  the  maintenance  and  advancement  of  his  power  of 
resistance.  The  human  economy  demands  for  its  sustenance  a  liberal 
supply  of  proteids  (to  build  up  and  to  reconstruct  the  tissues),  fat 
and  carbohydrates  (to  produce  energy  and  heat),  mineral  salts  (to 
help  formation  of  bones  and  teeth),  and  water  (to  aid  the  solubility 
of  the  food  elements  and  the  excretion  of  waste  products).  An  ideal 
food,  therefore,  must  contain  these  five  ingredients  in  more  or  less 
definite  proportion,  must  be  readily  digestible  and  assimilable,  and  be 
free  from  pathogenic  bacteria.     (See  Vitamines,  p.  114.) 

The  Digestibility  of  the  Proteins  of  Milk  and  Their  Role  in  Infant 

Nutritioi;* 

While  in  many  respects  our  ideas  of  infant  nutrition  and  feeding 
have  been  modified  by  the  clinical  and  laboratory  researches  of  the 
last  ten  or  fifteen  years,  probably  in  no  direction  has  the  change  of  view 
been  so  marked  as  that  regarding  the  proteins.  It  is  not  many  years 
since  the  difficult  digestion  of  cow's  milk  protein  was  looked  upon 
as  the  important,  probably  the  chief  cause  of  our  troubles  in  infant 
feeding,  and  many  were  the  expedients  resorted  to,  to  overcome  this 


*In  order  to  avoid  repetition,  and  also  to  give  the  student  the  latest  information  on  the 
subject,  we  are  here  abstracting  the  articles  on  "The  Digestibility  of  the  Proteins"  by  Br. 
Iv.  %  Holt,  and  "The  Digestion  of  the  Carbohydrates"  by  Dr&  J.  L,.  Morse  and  F.  B.Talbot. 


PREVENTION   AND    CONTROL   OF   DISEASE  27 

difficulty,  such  as  various  forms  of  diluent,  peptonizing,  the  addition 
of  sodium  citrate,  etc.  But  we  have  learned  that  the  symptoms  formerly 
ascribed  to  the  proteins  depend  upon  other  conditions.  The  curds  in 
stools  we  know  are  composed  chiefly  of  fat;  most  of  the  colic  and  flatu- 
lence are  due  to  carbohydrates,  and  constipation  depends  much  more  on 
fat  and  salts  than  on  casein.  All  researches  upon  gastric  digestion  in 
infants  agree  that  in  practically  all  conditions  pepsin  is  abundantly  se- 
creted. The  use  of  such  ferments  in  disturbances  of  digestion,  though 
still  widely  resorted  to,  has  no  rational  basis. 

Modern  practice  has  certainly  been  in  the  direction  of  using  much 
higher  proportions  of  protein  than  were  formerly  thought  wise  or  safe. 
It  is  interesting,  therefore,  to  inquire  whether  this  custom  is  justified 
by  our  present  knowledge  of  the  digestion  of  protein  by  the  infant; 
also  whether  it  is  advantageous  or  whether  its  use  is  fraught  with 
some  disadvantages  or  possible  dangers  not  apparent  on  the  surface. 

Metabolism  experiments  made  at  the  New  York  Babies'  Hospital  and 
in  many  other  places  have  revealed  the  fact  that  under  almost  all  cir- 
cumstances infants  possess  a  remarkable  capacity  for  retaining  nitrogen. 
Even  in  conditions  of  severe  malnutrition,  the  protein  of  cow's  milk  is 
well  borne,  as  shown  by  a  positive  nitrogen  balance,  even  though  the  in- 
fants were  losing  weight.  This  capacity  on  the  part  of  the  infant  to 
assimilate  protein  is  an  indication  of  how  well  nature  has  provided  the 
means  of  replacing  protein  waste  and  promoting  growth  above  other 
needs  of  the  organism. 

Clinical  evidence  of  the  infant's  tolerance  of  protein  is  also  not 
wanting.  When  the  question  is  asked,  What  are  the  symptoms  of  pro- 
tein indigestion  or  intolerance  ?  we  are  compelled  to  reply  that  at  pres- 
ent we  cannot  mention  any  definite  symptom  or  group  of  symptoms 
which  we  can  positively  attribute  to  the  proteins,  in  the  sense  that  we 
can  attribute  other  definite  symptoms  to  the  fats  and  to  the  carbohy- 
drates. 

Under  these  circumstances  it  is  pertinent  to  inquire  whether  the 
present  practice  of  giving  much  higher  proteins  than  formerly  is  one 
to  be  recommended  without  reservation;  is  this  safe?  is  it  advanta- 
geous? or  is  it  possibly  injurious? 

The  protein  needs  of  the  body  must  certainly  be  provided  for;  but 
is  it  desirable  to  go  much  beyond  this?  Many  elaborate  calculations 
have  been  made  to  determine  the  actual  protein  needs  of  the  infant. 
We  think  we  are  safe  in  assuming  that  they  are  supplied  in  woman's 
milk  in  sufficient  amount,  but  in  no  considerable  excess.  The  most  re- 
cent analyses  of  Courtney  and  Fales  show  that  during  the  mature 
period  of  lactation,  i.  e.,  after  the  first  month,  the  average  protein  con- 


28  DISEASES   OF    CHILDREN 

tent  of  woman's  milk  is  slightly  less  than  1.25  per  cent.  An  infant 
taking  cow's  milk,  as  it  is  now  usually  modified,  gets  very  much  more 
than  this. 

To  put  it  in  another  way,  assuming  an  average  composition  of  mature 
woman's  milk  to  be  3.5  per  cent  fat,  7.5  per  cent  sugar,  and  1.25  per 
cent  protein,  a  nursing  infant  is  receiving  a  little  over  7  per  cent  of  his 
calories  in  the  form  of  protein;  an  average  artificially -fed  infant  of 
three  months,  who  is  taking  cow's  milk  one-half  strength  with  sufficient 
sugar  added  to  bring  the  carbohydrates  up  to  6  per  cent,  is  receiving 
over  14  per  cent  of  his  calories  as  protein;  while  an  average  infant 
of  six  months,  who  is  getting  two-thirds  milk  with  the  same  propor- 
tion of  sugar,  is  receiving  nearly  17  per  cent  of  his  calories  in  the 
form  of  protein.  This  is  on  the  assumption  that  all  the  nitrogen  in 
woman's  milk  and  in  cow's  milk  is  alike  available  for  nutrition,  which 
is  not  quite  true.  While  this  is  very  nearly  the  case  with  cow's  milk, 
woman's  milk  is  known  to  contain  nitrogen  in  other  forms  than  protein 
(extractives,  urea,  etc.),  which  reduce  the  available  nitrogen  by  nearly 
one-fifth.  So  that  the  discrepancy  between  the  protein  content  of 
the  two  milks  is  even  greater  than  at  first  appears. 

Rubner  has  calculated  that  on  the  average  the  food  of  the  infant 
should  have  7  per  cent  of  his  calories  in  the  form  of  protein.  This  we 
have  already  seen  is  practically  that  which  is  present  in  woman's  milk. 
What  then  becomes  of  the  excess  of  protein  given  in  our  common  feed- 
ing mixtures?  Our  own  metabolism  experiments  have  shown  that  with 
high  protein  feeding  there  is  at  first  a  marked  increase  in  nitrogen  re- 
tention, but  that  this  persists  only  for  a  short  time  and  that  increased 
intake  is  followed  by  an  increased  excretion  which  is  nearly  but  not 
quite  proportional. 

Protein  is  needed  first  of  all  to  supply  the  nitrogenous  waste  of 
the  cells  of  the  body,  one  of  the  constant  phenomena  of  life ;  secondly 
for  growth;  and  lastly  it  may  supply  heat.  The  waste  or  "wear-and- 
tear-needs"  of  the  infant,  as  compared  with  the  needs  of  the  adult, 
are  not  great.  Growth,  according  to  Rubner,  is  not  in  proportion  to 
the  protein  intake  and  cannot  be  increased  above  natural  limits  by 
increasing  the  protein  intake.  The  excess  he  believes  is  simply  burned 
in  the  body  in  the  place  of  carbohydrate  and  fat.  The  inference  from 
his  observations  is  that  the  protein  requirements  of  the  infants  are 
relatively  small  and  that  if  taken  in  excess  of  this  minimal  requirement 
the  surplus  can  be  used  up  in  the  place  of  other  food  elements. 

Some  experimental  evidence  has  been  brought  forward  which  in- 
dicates that  we  may  not  continue  to  increase  the  protein  in  the  food 
without  incurring  some  risks;  that  the  protein  of  cow's  milk  when  given 


PREVENTION    AND    CONTROL   OF    DISEASE  29 

in  considerable  excess  of  the  needs  of  the  body  may  bring  about  dis- 
turbances of  metabolism  causing  clinical  symptoms  of  importance,  even 
of  gravity. 

In  a  series  of  metabolism  observations  made  four  years  ago  at  the 
Babies'  Hospital,  it  was  shown  that  if  large  amounts  of  protein  of 
cow's  milk  were  given  without  whey  (i.  e.,  without  carbohydrates) 
certain  definite  symptoms  regularly  followed — prostration,  fever  and  a 
leukocytosis,  which  symptoms  ceased  immediately  upon  resuming  the 
ordinary  diet. 

Observations  in  Lusk's  laboratory  by  Rowland  and  also  by  Murlin 
and  Hoobler  have  shown  that  an  increase  in  the  amount  of  protein 
given  caused  an  immediate  and  very  marked  increase  in  the  general 
metabolism,  and  also  that  if  fat  and  carbohydrates  were  not  furnished 
in  the  food  in  sufficient  amount,  the  increased  metabolism  caused  an 
actual  loss  of  these  substances  from  the  tissues  of  the  body.  In  Hoob- 
ler's  case  there  was  observed  diarrhea  and  a  condition  of  semistupor. 

Symptoms  like  those  mentioned  in  the  foregoing  observations  have 
been  seen,  it  is  true,  only  when  protein  is  given  very  much  in  excess  of 
the  amounts  commonly  employed.  The  cause  of  these  symptoms  is 
not  yet  understood  and  while  the  observations  are  by  no  means  con- 
clusive, they  are  strongly  suggestive  of  possible  harm  which  may  re- 
sult from  very  high  protein  feeding.  The  increase  in  the  general  metab- 
olism from  such  feeding,  and,  under  certain  circumstances,  the  actual 
withdrawal  of  fat  and  carbohydrate  from  the  body,  may  furnish  an 
explanation  of  why  it  is  so  difficult  to  increase  weight  if  fat  and  carbo- 
hydrate, but  especially  the  latter,  are  much  reduced. 

Thus  far  we  have  considered  the  protein  needs  of  the  infant  only 
from  a  quantitative  standpoint,  and  until  quite  recent  times  this  has 
been  the  chief  subject  of  discussion.  The  only  differences  between 
proteins  have  been  indicated  by  that  somewhat  vague  term  of  "diges- 
tibility." The  latest  studies  of  the  food  proteins  indicate  that  the 
amount  of  protein  given  is  much  less  important  than  the  nature  of  the 
protein  furnished.  We  have  learned  from  Abderhalden  that  our  com- 
mon food  proteins  are  very  complex  substances,  being  made  up  of 
some  sixteen  or  eighteen  different  amino-acids. 

Osborne  and  Mendel  have  for  years  been  carrying  on  an  extensive 
series  of  feeding  experiments  upon  animals  to  determine  the  specific 
value  of  the  different  amino-acids  in  nutrition.  They  have  shown  that 
certain  amino-acids  are  indispensable  for  growth;  others  are  relatively 
unimportant.  Thus  if  gliadin,  a  wheat  protein,  be  the  form  of  protein 
given  to  the  animal,  although  the  animal  may  maintain  its  weight, 
no  growth  occurs.    But  if  to  this,  without  increasing  the  total  protein, 


30  DISEASES   OF   CHILDREN 

a  small  amount  of  one  of  the  amino-acids  known  as  lysin  is  added,  a 
gain  in  weight  begins  immediately  and  continues  as  long  as  lysin  is 
administered;  but  it  ceases  at  once  when  it  is  withheld,  and  begins 
when  it  is  again  furnished  to  the  animal.  From  many  such  experi- 
ments they  have  reached  the  conclusion  that  lysin  is  indispensable  for 
growth;  without  it,  no  matter  what  amount  of  protein  food  is  given, 
the  most  that  the  animal  can  do  is  to  maintain  itself  in  equilibrium. 
There  are  three  other  amino-acids  of  great  importance — cystin,  tryp- 
tophan and  glycocoll.  It  does  not  seem  possible  for  normal  nutrition 
to  go  on  unless  lysin,  tryptophan  and  cystin  are  furnished  in  the  food ; 
glycocoll  alone,  there  is  good  reason  for  believing,  can  be  produced 
in  the  body  by  synthesis. 

Now  as  to  the  bearing  of  this  on  infant  feeding.  Animal  proteins, 
as  a  rule,  are  relatively  rich  in  those  amino-acids  which  we  will  call 
the  essential  ones,  while  many  vegetable  proteins  are  very  deficient 
in  them.  But  again  there  is  a  wide  difference  in  the  amino-acid  con- 
tent of  the  different  animal  proteins.  Lactalbumin  is  the  protein 
which  contains  the  essential  ones  in  largest  proportion.  Casein,  how- 
ever, is  notably  deficient  in  at  least  one  important  one,  cystin.  Men- 
del says  if  the  supply  of  casein  is  limited,  the  curve  of  growth  is  al- 
tered, not  for  lack  of  total  protein,  which  may  be  entirely  adequate, 
but  for  lack  only  of  cystin,  for  as  soon  as  this  is  added  to  the 
food,  normal  growth  at  once  begins.  Growth,  therefore,  is  limited  by 
the  supply  of  cystin.  The  deficiencies  of  casein  are  ordinarily  made 
good  by  the  amino-acids  of  lactalbumin.  And  right  here  it  should 
be  remembered,  that  in  woman's  milk  the  amount  of  lactalbumin  is 
twice  the  casein,  while  in  cow's  milk  it  is  only  one-sixth  the  casein. 
It  is  surely  not  an  accident  that  woman's  milk  has  relatively  twelve 
times  as  much  lactalbumin  as  has  cow's  milk. 

Woman's  milk  supplies  not  only  the  amount  of  protein  needed  by 
the  infant  for  the  first  eight  or  nine  months  of  life,  it  furnishes  what 
is  more  important,  the  essential  amino-acids  in  sufficient  quantity. 
There  are  good  reasons  for  believing  that  nature  has  not  intended 
cow's  milk  to  nourish  even  the  calf  for  &  very  long  period.  The 
maximum  secretion  of  cow's  milk  is  reached  at  the  beginning  of  the 
second  month,  after  which  it  steadily  declines.  Moreover,  the  calf 
at  birth  usually  has  eighteen  teeth,  indicating  again  his  early  capacity 
for  digesting  other  food  than  milk  and  also  his  need  of  it.  Now,  the 
secretion  of  woman's  milk  increases  in  quantity  under  normal  con- 
ditions up  to  eight  or  nine  months,  and  the  human  infant  does  not 
get  his  teeth  until  seven  or  eight  months — a  strong  suggestion  that 
up  to  this  time  other  food  is  unnecessary  for  normal  nutrition.     But, 


PREVENTION   AND    CONTROL   OF   DISEASE  31 

in  the  case  of  infants  who  are  artificially  fed,  conditions  are  different ; 
although  the  defects  of  cow's  milk  have  not  been  wholly  understood, 
we  have  lately  seen  the  great  advantage  of  the  earlier  use  of  other  ar- 
ticles of  diet — fruit  juices,  beef  juice,  egg,  broth  and  even  fresh  veg- 
etables. Thus  we  have  been  unconsciously  doing  what  the  calf  has 
been  doing  for  a  very  long  time — supplying  the  deficiencies  of  cow's 
milk. 

Returning  to  the  subject  of  casein,  Osborne  and  Mendel  have  found 
that  the  gain  in  weight  with  9  per  cent  of  the  food  solids  in  the  form 
of  casein  was  very  low  unless  cystin  was  added,  but  if  the  casein 
was  doubled  or  increased  to  18  per  cent,  a  normal  rise  in  weight  was 
seen.  We  have  here,  we  believe,  a  important  fact  which  sheds  light 
on  some  of  our  failures  and  successes  in  infant  feeding.  We  once 
thought  that  we  were  supplying  the  infant's  protein  needs  when  we 
gave  as  much  protein  in  cow's  milk  as  the  protein  in  woman's  milk. 
Evidently  we  were  wrong.  It  now  seems  clear  that  some  of  our  fail- 
ures were  not  due  to  the  fact  that  we  were  giving  too  much  fat,  but 
that  we  were  not  supplying  in  the  protein  given  the  amino-acids  re- 
quired for  normal  growth. 

The  success  which  has  attended  the  use  of  formulas  made  from 
whole  milk  has  not  been  entirely  due  to  the  fact  that  the  fat  dis- 
turbances have  been  avoided,  but  that  in  these  formulas  by  greatly  in- 
creasing the  protein  we  have  come  much  nearer  supplying  the  in- 
fant's actual  amino-acid  needs  of  growth,  especially  in  lysin  and  cystin. 
The  excess  of  other  protein  food  apparently  is  not  injurious. 

We  have  seen  thus  far  (1)  that  the  digestion  of  the  protein  of  cow's 
milk  is  a  much  easier  matter  than  was  formerly  supposed;  (2)  that 
while  injury  may  without  question  be  done  by  high  protein  feeding, 
this  is  very  unlikely  to  occur,  unless  amounts  much  in  excess  of  those 
commonly  used  in  infant  feeding  are  administered;  (3)  that  in  such 
amounts  we  have  as  yet  neither  clinical  nor  laboratory  evidence  to 
show  that  protein  is  harmful;  (4)  that  although  an  infant  receiving 
breast  milk  takes  rather  less  than  7  per  cent  of  his  calories  as  pro- 
tein, this  cannot  be  taken  as  an  exact  criterion  of  how  much  protein 
should  be  administered  when  cow's  milk  is  the  food;  (5)  that  the 
deficiency  of  cow's  milk  casein  in  certain  essential  amino-acids  may 
be  ma^e  up  by  giving  an  excess  of  this  protein. 

There  remains  for  brief  consideration  the  clinical  use  which  may 
be  made  of  these  facts,  not  now  in  the  feeding  of  healthy  infants, 
but  in  the  diet  of  those  who  are  suffering  from  the  most  common  forms 
of  digestive  disturbances — intolerance  of  fat  or  carbohydrates  or  both. 
The  great  advantages  of  high  protein  feeding  and  the  extent  to  which 


32  DISEASES   OF    CHILDREN 

proteins  are  borne  we  have  only  recently  appreciated.  That  an  infant 
of  four  or  five  months  could  easily  tolerate  a  milk  mixture  containing 
as  much  as  3.5  or  even  4  per  cent  of  protein  has  been  to  most  of  us 
a  surprise,  especially  when  the  protein  given  is  nearly  all  casein.  In 
our  experience,  in  acute  intestinal  disturbances  it  is  the  carbohydrates 
that  are  most  frequently  at  fault,  and  sugars  are  even  more  badly  borne 
than  starches.  Milk  sugar  seems  then  to  cause  more  disturbance  than 
any  other  form  of  carbohydrate.  It  is  for  such  cases  that  Finkel- 
stein's  milk  modification — best  translated  into  English  as  protein  milk 
(q.  V.) — is  so  valuable.  Its  usefulness  is  seldom  enhanced  by  preparing 
it  from  skimmed  milk,  but,  in  my  experience,  rather  the  contrary.  For 
its  relatively  high  fat  is  usually  tolerated  without  difficulty  when  low 
sugar  is  given.  This  preparation  is  to  be  regarded  as  a  therapeutic 
agent,  not  a  method  of  infant  feeding,  but  it  is  one  of  the  most  valua- 
ble additions  to  our  resources  that  has  been  made  in  recent  years. 

Physiology  and  Pathology  of  the  Digestion  of  the  Carbohydrates  in 

Infancy* 

Physiology;  Ferments.— Zwief el,  1874,  and  Korowin,  1875,  were  un- 
able to  find  a  diastatic  ferment  in  the  pancreas  of  the  newborn,  and 
to  this  fact  is  due  most  of  the  misconceptions  concerning  the  power  of 
digesting  starch  in  infancy.  The  work  which  corrected  this  impres- 
sion will  be  quoted  later. 

Saliva. — Zwiefel  found  diastase  in  the  parotid  gland  of  the  newly 
born  but  was  unable  to  find  it  in  the  submaxillary.  Ibrahim,  after  a 
prolonged  piece  of  work,  found  it  in  both  the  parotid  and  submaxillary 
glands,  its  action  being  stronger  in  the  former  than  in  the  latter.  Di- 
astase was  found  much  earlier  in  fetal  life  in  the  parotid  than  in  the 
submaxillary,  traces  being  found  in  the  former  at  the  fourth  and  in  the 
latter  at  the  sixth  month  of  fetal  life.  The  diastase  of  the  parotid  is  the 
earliest  digestive  ferment  found  in  the  embryo. 

A  diastatic  ferment  can  always  be  found  in  the  saliva  of  healthy 
infants.  The  diastatic  action  of  saliva  may  continue  in  the  stomach  as 
long  as  two  hours  after  feeding. 

Stomach. — Ibrahim  is  the  only  worker  who  has  examined  the  gastric 
mucous  membrane  of  the  newborn  for  the  carbohydrate  splitting  fer- 
ments, and  he  has  been  unable  to  find  either  lactase,  maltase  or  invertin. 

Pancreas. — Moro  was  able  to  demonstrate  the  presence  of  amylo- 
lytic  ferment  in  the  pancreas  of  newly  born  babies  when  the  pancreas 
was  thoroughly  extracted,  and  thus  disproved  the  earlier  work  of  Zwie- 
fel and  Korowin.     Ibrahim  never  failed  to  get  the  ferment  in  a  six 


*See  foot  note  p.  26. 


PREVENTION    AND    CONTROL   OF   DISEASE  33 

months'  fetus  when  he  tested  the  action  of  the  ferment  on  starch  meal. 
He  was,  however,  unable  to  find  it  when  he  tested  soluble  {i.  e.,  cooked) 
starch. 

Ibrahim  was  unable  to  demonstrate  invertin  and  lactase  in  the  pan- 
creas of  the  newborn  or  older  babies,  but  he  was  usually  able  to  dem- 
onstrate maltase  in  the  newborn  and  always  in  older  children.  Maltase 
may  also  be  found  in  the  blood. 

Small  Intestine. — The  mucous  membrane  of  the  small  intestine  con- 
tains amylolytic  ferments. 

Lactase,  the  ferment  which  splits  milk  sugar,  has  been  repeatedly 
found  in  the  mucous  membrane  of  the  small  intestine.  Ibrahim  always 
found  it  in  the  small  intestine  and  meconium  of  newly  born  babies,  but 
was  unable  to  find  it  in  premature  infants.  He  says,  however,  that 
his  method  of  determining  lactase  is  not  capable  of  demonstrating  small 
amounts.  Lactase  is  more  abundant  in  the  young  animal  than  in  the 
adult. 

Pautz  and  Vogel  found  maltase,  the  ferment  which  splits  malt  sugar, 
in  the  small  intestine  of  infants. 

Invertin,  the  ferment  which  splits  cane  sugar,  was  found  in  the  se- 
cretions of  the  small  intestine  of  the  newborn  by  Miura,  and  Ibrahim 
was  always  able  to  demonstrate  its  presence  both  in  the  intestinal 
mucous  membrane  and  in  the  intestinal  contents  of  all  fetuses. 

Large  Intestine. — It  is  difficult  to  wash  the  large  intestine  free  from 
meconium,  and  the  results  of  the  examinations  of  its  mucous  membrane 
are  variable,  as  the  tables  of  Miura,  Pautz  and  Vogel  show.  It  is,  there- 
fore, impossible  to  say,  whether  it  contains  ferments  or  not. 

Stools. — Pottevin  found  an  amylolytic  ferment  in  the  meconium. 
Kerley,  Mason  and  Craig  were  able  to  demonstrate  the  presence  of  a 
strong  amylolytic  ferment  in  the  stools  of  very  young  babies,  the  possi- 
bility of  the  bacterial  fermentation  of  starch  being  excluded.  There 
is  a  larger  amount  of  diastase  in  the  stools  of  breast-fed  babies  than 
in  those  of  the  bottle-fed,  which  Hecht  believes  to  be  due  to  the  fact 
that  the  intestinal  contents  of  the  breast-fed  baby  pass  more  quickly 
through  the  intestinal  canal  than  do  those  of  the  bottle-fed  baby. 

The  power  of  digesting  starch,  while  occasionally  absent,  is,  there- 
fore, almost  always  present  both  in  the  fetus  and  in  the  newly  born. 
Hedenius'  experiments  show  that  it  is  less  powerful  in  young  babies 
than  in  later  life.  Young  babies  are  nevertheless  able  to  adapt  them- 
selves to  a  food  rich  in  carbohydrates.  There  is,  according  to  Moro, 
.  a  rapid  increase  in  the  power  of  digesting  starch  during  the  first  week 
of  life.  The  baby,  therefore,  has  a  power  of  digesting  starch  at  birth 
which  gradually  increases  in  strength  as  the  baby  grows  older.     Ac- 


34 


DISEASES   OF    CHILDREN 


cording  to  Finizio,  it  is  twice  as  strong  at  eight  months  as  it  is  at 
birth,  while  at  twelve  months  it  is  almost  as  strong  as  at  three  years. 

The  question  whether  the  carbohydrate-splitting  ferments  are  af- 
fected by  disease  has  been  answered  only  in  part.  Orban  found  by 
animal  experimentation  that  an  injured  intestinal  mucous  membrane 
contained  no  lactase,  and  that  the  stools  of  babies  ill  with  enteritis 
contained  no  lactase.  Langstein  and  Steinitz,  on  the  other  hand, 
always  found  lactase  in  the  stools  of  babies  ill  with  enteritis,  whether 
mild  or  severe,  acute  or  chronic. 

Forms  of  Carbohydrates.— The  carbohydrates  used  in  infant  feed- 
ing may  be  divided  into  the  following  groups : 


Milk   Sugar  Group 


Lactose    (milk   sugar) 

t 
Dextrose  +  Galactose 


Cane    Sugar  Group 


Saccharose  (cane  sugar) 

X 

Dextrose  +  Levulose 


Malt  Sugar  Group 


Starch  (amylum) 

Dextrin    (amylo- 
dextrin) 

I 
Erythro-   and   Achro- 
dextrin 

I 
Maltose    (malt  sugar) 

t 
Dextrose  +  Dextrose 


Poly- 
saccharide 


Di- 

saccharide 

Mono- 
saccharide 


Digestion  of  Carbohydrates. — The  carbohydrates  are  broken  down 
during  digestion  into  the  simplest  forms  of  sugar,  the  monosaccharides, 
by  the  various  ferments  described  above.  According  to  Rohrmann 
a  considerable  amount  of  the  disaccharides  may  pass  into  the  intes- 
tinal mucous  membrane  and  these  be  split  into  monosaccharides.  The 
monosaccharides  are  carried  by  the  portal  vein  to  the  liver,  Avhere 
they  are  transformed  into  glycogen,  the  only  difference  being  that  dex- 
trose is  more  easily  converted  than  levulose  or  galactose.  The  pan- 
creas has  some  influence  on  this  process,  because  extirpation  of  the 
pancreas  in  dogs  results  in  sugar  in  the  urine  and  interferes  with 
the  formation  of  glycogen  in  the  liver.  The  liver  actually  has  the 
property  of  forming  glycogen  from  sugar. 

The  purpose  of  the  splitting  of  the  poly-  and  disaccharides  into 
monosaccharides  is  to  prepare  them  for  use  inside  the  body,  because 
the  unsplit  carbohydrates  are  not  burned  up  in  the  body  but  are  ex- 
creted in  the  urine.  The  transformation  of  sugar  into  glycogen,  which 
is  deposited  in  the  liver  and  muscles,  is  of  great  importance,  because 
this  glycogen  can  be  broken  down  again  into  sugar  according  to  the 
needs  of  the  body.  The  monosaccharides  are  absorbed  more  quickly 
than  the  disaccharides. 


PREVENTION    AND    CONTROL    OF    DISEASE  35 

A  large  part  of  the  digestion  and  absorption  of  the  carbohydrates 
takes  place  in  the  upper  part  of  the  small  intestine,  but  splitting 
and  absorption  may  also  take  place  in  the  large  intestine. 

There  is  normally  about  1-10  per  cent  of  dextrose  in  the  blood. 
The  slightest  disturbance  of  the  regulating  apparatus  will  cause 
a  hyperglycemia  which  results  in  glycosuria.  A  deficit  of  sugar  in 
the  blood  is  made  up  from  the  glycogen  deposits. 

Albertoni  and  Hedon  found  that  sugars  have  a  purgative  action  when 
they  are  given  in  large  enough  amounts.  This  action  is  more  marked 
when  they  are  taken  in  concentrated  solution.  All  sugars  have  this 
action,  the  difference  between  them  being  only  in  degree.  They  found 
that  glucose  and  cane  sugar  are  much  more  quickly  absorbed  than 
lactose,  and  that  the  former  has  less  of  a  purgative  action  than  the 
latter. 

Little  or  no  sugar  can  be  found  in  the  stools  under  normal  condi- 
tions, but  when  the  food  passes  rapidly  through  the  intestinal  canal, 
as  it  does  when  peristalsis  is  rapid  as  the  result  of  disease  or  indiges- 
tion, sugar  can  be  found  in  the  stool  (Hecht).  Usually  only  the  prod- 
ucts of  the  decomposition  of  sugar  can  be  isolated. 

Hedenius  fed  babies  with  milk  mixed  with  wheat  flour,  oat  gruel 
or  Keller's  malt  extract  and  measured  the  amount  of  carbohydrates 
ingested,  the  amount  in  the  stools,  and  their  acidity.  He  found  that 
when  simple  cereals  were  used,  less  carbohydrate  was  found  in  the 
stools  than  with  complicated  mixtures  and  that  the  more  carbohydrate 
in  the  stool,  the  greater  its  acidity.  He  never  found  more  than  3  per 
cent  of  the  ingested  carbohydrate  in  the  stool  in  any  instance.  Kel- 
ler has  shown  that  carbohydrates  make  the  digestion  of  protein  more 
complete. 

Metabolism  of  Carbohydrates. — Numerous  observations  have  shown 
that  when  milk  sugar  is  injected  directly  into  the  circulation  it  may 
be  completely  recovered  in  the  urine.  Grosz  was  never  able  to  de- 
tect milk  sugar  in  the  urine  of  healthy  babies,  but  found  it  in  the 
urine  of  those  suffering  from  gastrointestinal  disease,  in  which  there 
was  presumably  an  absence  of  lactase  in  the  intestine.  Langstein 
and  Steinitz  repeated  Grosz 's  experiments  and  in  certain  instances 
found  lactase  in  the  stools  at  the  same  time  that  sugar  was  being 
excreted  in  the  urine.  This  sugar  was,  moreover,  not  always  lac- 
tose, but  sometimes  galactose,  one  of  the  products  of  the  splitting 
of  lactose.  They  tried  to  explain  this  as  follows :  that  some  of  the 
sugar  passes  through  functional  or  anatomic  lesions  of  the  intestinal 
wall  before  it  is  completely  broken  up  and  is  excreted  in  the  urine 
as  an  intermediary  product  of  metabolism. 


36  DISEASES   OF    CHILDREN 

Mendel  and  Kelimer  have  shown  that  when  cane  sugar  is  intro- 
duced subcutaneously  into  dogs  or  cats  in  doses  of  1  to  2  grams  per 
kilogram  of  body  weight,  it  is  not  completely  recovered  in  the  urine. 
The  quantity  excreted  amounts,  as  a  rule,  to  more  than  65  per  cent 
of  that  introduced.  The  excretion  begins  within  a  few  minutes  and 
is  usually  completed  within  thirty-six  hours,  Fisher  and  Moore 
draw  attention  to  the  possibility  that  the  sugar  thus  introduced  may 
be  excreted  through  the  walls  of  the  alimentary  tract  and  there  be 
digested.  These  views  are  supported  by  Japelli  and  D'Errico,  who 
conclude  from  their  experiments  on  dogs  that  when  cane  sugar  is  in- 
troduced directly  into  the  circulation  the  quantity  eliminated  in  the 
urine  is  never  equivalent  to  the  amount  injected.  This  causes  both 
glycosuria  and  saccharosuria,  the  former  disappearing  first.  The 
blood  has  no  power  of  converting  cane  sugar.  According  to  these 
writers,  cane  sugar  introduced  intravenously  is  eliminated  into  the 
alimentary  tract  through  the  gastric  mucosa,  the  salivary  glands  and, 
to  an  insignificant  degree,  through  the  bile.  The  subsequent  fate 
of  this  component  is  obvious. 

According  to  Finkelstein,  sugars  may  cause  fever.  This  so-called 
sugar  fever  has  been  studied  especially  by  his  pupils.  Leopold  found 
that  43  per  cent  of  the  babies  tested  with  lactose,  47  per  cent  of 
those  with  glucose,  42  per  cent  of  those  with  saccharose  (cane  sugar), 
and  33  per  cent  of  those  wdth  maltose,  reacted  with  fever.  This  fever 
was  always  accompanied  by  diarrhea,  and  in  none  of  the  cases  tested 
in  which  the  stools  remained  normal  did  the  sugar  cause  fever. 

The  limits  of  assimilation  of  the  different  sugars  vary  and  are  as 
follows : 

Grape  Sugar. — In  babies,  about  5  grams  per  kilogram  (Langstein 
and  Meyer). 

Grape  Sugar. — In  one-month  baby,  8.6  grams  per  kilogram  (Green- 
field). 

Galactose. — No  accurate  data. 

Levulose. — Lower  for  babies  than  adults.  One  gram  per  kilogram 
(Keller). 

Maltose. — Over  7.7  grams  per  kilogram  (Reuss). 

Lactose. — 3.1  to  3.6  grams  per  kilogram  (Grosz). 

Cane  Sugar. — Probably  about  the  same  as  lactose  (Reuss). 

Escherich  divides  the  digestive  disturbances  of  infancy  into  two  main 
types:  (a)  Fermentation  with  the  formation  of  acid  products,  and  (6) 
putrefaction  with  the  formation  of  alkalies.  These  two  processes  are  an- 
tagonistic to  one  another,  the  basis  of  fermentation  being  carbohydrates 
and,  of  putrefaction,  protein.  An  excessive  preponderance  of  one  over 
the  other  may  do  harm.    Fermentation  results  in  an  excessive  formation 


PREVENTION    AND    CONTROL   OF   DISEASE  37 

of  acids,  especially  of  lactic  acid  from  lactose.  This  may  cause  a  large 
number  of  stools  as  the  result  of  the  increased  peristalsis  and  the  flow 
of  serous  fluid  or  cellular  exudate.  Eazenski  has  shown  that  in  babies 
sick  with  what  he  calls  "dyspepsia  intestinalis  acida  lactorum"  there 
is  an  increased  acidity  of  the  intestinal  contents  and  that  the  utili- 
zation of  fat  is  diminished.  Meyer  and  Leopold  intimate  that  a  sugar 
indigestion  may  cause  the  appearance  of  casein  curds. 

Finkelstein  and  Meyer  believe  that  milk  sugar  is  the  primary  cause 
of  the  fermentative  dyspepsias  of  infancy  and  that  when  there  is  a 
disturbance  of  the  utilization  of  fat  in  these  conditions  it  is  a  secon- 
dary manifestation.  They  claim  that  these  dyspepsias  can  be  relieved 
by  the  long-continued  diminution  of  the  carbohydrates  in  the  food 
and  quickly  cured  by  the  withdrawal  of  milk  sugar  and  the  adminis- 
tration of  large  amounts  of  casein  {Eiweissmilch).  In  general,  the 
fermentation  of  the  sugar  depends  upon  the  relation  between  the 
casein  and  the  sugar  in  the  food.  They  advise  the  administration  of 
other  easily  assimilable  and  consequently  little  fermentable  carbo- 
hydrates, such  as  maltose,  in  place  of  lactose,  after  the  disappearance 
of  the  acute  symptoms.  Birk  and  Reuss  and  Sperk  have  confirmed 
their  observations.  Braumiiller  called  attention,  however,  to  the  dan- 
ger of  the  sudden  addition  of  sugar  to  the  diet  after  it  has  been 
withdrawn  and  large  amounts  of  casein  given,  believing  that  under 
these  conditions  the  ability  to  form  the  ferments  necessary  to  take 
care  of  sugar  is  practically  abolished. 

Kendall  has  shown  that  the  colon  bacillus,  like  the  diphtheria  and 
tetanus  bacilli,  causes  fermentation  or  putrefaction  according  to 
whether  it  is  in  a  carbohydrate  or  protein  medium,  that  it  attacks  the 
sugar  in  preference  to  the  protein  of  the  medium  and  that  until  the 
carbohydrate  is  used  up  the  protein  is  shielded  from  attack.  The 
products  of  the  fermentation  of  carbohydrates  are  acid.  He  also 
showed  that  the  Shiga  bacillus  produces  toxin  only  when  the  medium 
has  an  alkaline  reaction.  He,  therefore,  proposed  feeding  babies  ill 
with  bacillary  dysentery  with  an  easily  fermentable  carbohydrate  in 
order  to  change  the  character  of  the  bacterial  activity  in  the  alimen- 
tary canal  from  the  proteolytic  to  the  fermentative  type.  The  result 
is  to  stop  further  formation  of  toxin.  This  was  done  by  feeding  the 
babies  a  5  per  cent  lactose  solution,  under  the  influence  of  which 
the  dysentery  bacillus  and  streptococci  tend  to  disappear. 

Fat  Metabolism 

The  infant  obtains  its  required  amount  of  fat  elements  in  the  breast 
or  bottle  milk.  But  whereas  the  infantile  system  assimilates  almost 
96  per  cent  of  the  fat  of  breast  milk,  it  absorbs  only  80  per  cent  of  that 


38  DISEASES   OF    CHILDREN 

of  cow's  milk.  Furthermore,  the  daily  loss  of  fat  by  infants  fed  on 
mother's  milk  is  only  half  as  great  as  that  of  eow's  milk.  As  in  adults 
so  in  children  fat  plays  an  important  role  in  the  maintenance  of  body 
heat  and,  if  combined  with  proteids,  it  saves  nitrogenous  waste  and  to 
a  certain  extent  replaces  the  carbohydrates. 

The  fats  of  the  milk  pass  unchanged  into  the  duodenum.  Here  they 
are  partly  emulsified  and  in  part  split  up  by  the  pancreatic  juice  into 
fatty  acids  and  glycerine,  and  thus  largely  absorbed  by  the  intestinal 
villi.  The  unassimilated  fat  passes  out  with  the  feces  as  neutral  fats, 
fatty  acids  and  soap. 

L.  E.  Holt,  A.  M.  Courtney  and  H.  L.  Fales,  have  made  a  very  ex- 
haustive study  of  the  "Fat  Metabolism  of  Infants  and  Young  Chil- 
dren" (Am.  Jour.  Dis.  Child.  Vol.  xvii  and  xviii,  1919)  and  arrived  at 
the  following  conclusions  regarding 

FAT  RETENTION  AND  EXCRETION  IN 
RELATION  TO  DIET 

I.  Fat  in  the  Stools  of  Breast  Fed  Infants 

1.  The  fat  of  the  stools  of  normal  breast  fed  infants,  according  to 
their  observations,  averaged  34.5  per  cent  of  the  dried  weight  and 
frequently  was  as  high  as  50  per  cent. 

2.  The  soap  fat  in  the  best  stools  predominated  over  the  other  forms 
of  fat,  averaging  57.8  per  cent  of  the  total  fat,  as  determined  on  the 
dried  stool.  The  average  stool  of  the  normal  breast  fed  infants  showed 
a  soap  fat  of  43.1  per  cent  of  the  total  fat,  as  determined  on  the  dried 
stool,  which  would  correspond  to  over  one-third  of  the  total  fat  of 
the  fresh  stool. 

3.  The  neutral  fat  in  the  best  stools  averaged  15.9  per  cent  of  the 
total  fat;  in  the  average  stool  the  neutral  fat  was  20.2  per  cent  of  the 
total  fat.  The  amount  of  neutral  fat  is  not  affected  by  the  drying 
process. 

4.  No  constant  relation  Avas  shown  between  the  per  cent  of  fat  in 
the  mother's  milk  and  the  per  cent  of  total  fat  and  its  distribution  in 
the  stool. 

5.  With  a  higher  total  intake  of  fat,  the  fat  per  cent  and  the  soap 
fat  in  the  stool  were  somewhat  increased. 

6.  A  range  of  fat  absorption  from  90.3  to  99.2  per  cent  of  the  intake 
was  found  in  healthy  breast  fed  infants. 


PREVENTION    AND    CONTROL    OF    DISEASE  39 

II.  Fat  in  the  Stools  of  Infants  Fed  on  Modifications 

of  Cow's  Milk 

1.  The  material  presented  in  this  article  comprised  the  results  of 
analysis  of  128  stools  of  seventy-seven  infants  whose  ages  ranged  from 
2  to  18  months,  fed  on  modifications  of  cow's  milk. 

2.  The  average  fat  per  cent  of  the  dried  weight  in  normal  stools 
Avas  36.2.  The  hard,  constipated  stools  showed  no  variation  from  this 
figure.  In  the  stools  not  quite  normal  in  appearance  the  average  fat 
per  cent  was  slightly  lower.  In  severe  diarrhea  the  fat  per  cent  of 
dried  weight  was  much  higher,  reaching  an  average  of  40.7  per  cent. 

3.  The  soap  per  cent  of  total  fat  Avas  very  high  in  both  normal 
and  constipated  stools,  averaging,  respectively,  72.8  and  73.8  per  cent. 
As  the  stools  became  less  normal  in  appearance  the  soap  fat  diminished 
rapidly  and  averaged  in  the  loose  stools  only  30.6  per  cent  of  the 
total  fat,  in  the  diarrheal  stools  12.4  per  cent,  and  in  those  of  severe 
diarrhea  only  8.8  per  cent  of  the  total  fat. 

4.  The  neutral  fat  was  less  than  10  per  cent  of  the  total  fat  in 
normal  and  constipated  stools.  It  increased  as  the  soap  fat  diminished 
and  in  diarrheal  conditions  made  up  about  60  per  cent  of  the  total  fat 
in  the  stool. 

5.  The  free  fatty  acids  constituted  about  17  per  cent  of  the  total 
fat  of  normal  and  of  constipated  stools.  It  was  increased  somewhat 
as  the  stools  became  less  like  the  normal  and  in  the  diarrheal  stools 
was  over  30  per  cent  of  the  total  fat  of  the  stool. 

6.  No  definite  relationship  was  shown  between  the  daily  fat  intake 
and  the  per  cent  of  fat  or  the  distribution  of  fat  in  the  stool. 

7.  The  average  per  cent  of  the  fat  retained  with  normal  stools 
was  91.3  per  cent  of  the  intake.  The  retention  was  but  little  lower 
when  the  stools  were  somewhat  harder  or  softer  than  normal,  or 
were  not  homogeneous,  or  contained  more  or  less  mucus  without  being 
distinctly  watery.  As  the  water  in  the  stools  increased,  the  per  cent 
of  retention  dropped  markedly,  reaching  in  severe  diarrhea  58.4  per 
cent  of  the  intake. 

8.  There  was  no  striking  relation  between  the  fat  intake  and  the 
per  cent  of  the  intake  retained,  except  when  the  intake  was  abnor- 
mally low. 

III.  Fat  in  the  Stools  of  Children  on  a  Mixed  Diet 

1.  In  the  normal  or  constipated  stools  of  older  children  whose  diet 
consisted  of  milk  alone  or  milk  with  bread  and  cereal  the  fat  per- 
centage of  dried  weight  averaged  30.7,  which  is  lower  than  the  average 


40  DISEASES   OF    CHILDREN 

found  for  similar  stools  of  infants  taking  modifications  of  cow's  milk. 
The  soap  percentage  of  total  fat  averaged  60.9,  which  was  somewhat 
lower  than  that  found  in  the  stools  of  the  infants. 

2.  The  normal  and  the  constipated  stools  of  children  on  a  mixed 
diet  showed  almost  identical  average  values  both  for  fat  percentage  of 
dried  weight  and  for  distribution  of  fat.  The  fat  percentage  of  dried 
weight  averaged,  respectively,  18.0  and  20.1,  and  the  soap  averaged, 
respectively,  45.1  and  47.9  per  cent  of  the  total  fat.  These  values 
were  much  lower  than  those  found  when  the  diet  contained  little  or 
no  solid  food. 

3.  In  the  acid  abnormal  stools  of  children  on  a  mixed  diet  the  fat 
averaged  15.1  per  cent  of  the  dried  weight.  Both  the  fat  percentage 
of  dried  weight  and  the  soap  percentage  of  total  fat  were  much  lower 
than  in  normal  stools  and  the  values  for  fatty  acids  and  for  neutral 
fat  were  higher. , 

4.  With  rachitic  children  the  fat  percentage  of  dried  weight  aver- 
aged 34.7  in  the  alkaline  stools,  and  24.6  in  the  acid  stools..  The  values 
were  higher  than  those  found  for  corresponding  types  of  stools  of 
normal  children.  The  proportions  of  soap,  fatty  acids  and  neutral  fat 
were  not  significantly  different  from  those  for  normal  children. 

5.  The  stools  of  children  suffering  from  chronic  intestinal  indiges- 
tion showed  a  much  higher  fat  percentage  of  dried  weight  than  those 
of  normal  children ;  the  average  for  alkaline  stools  being  36.4  per  cent, 
and  for  acid  stools  35.3  per  cent.  The  average  percentage  of  neutral 
fat  was  lower  in  both  alkaline  and  acid  stools  of  these  children  than  in 
the  stools  of  normal  children.  The  fatty  acids  were  higher  than 
normal,  much  higher  when  the  reaction  of  the  stools  was  acid. 

6.  The  average  fat  loss  in  the  stools  of  normal  children  varied 
between  2.6  and  3.0  gm.  in  all  the  groups  studied,  being  highest  in  the 
stools  of  children  whose  diet  contained  the  smallest  proportion  of  solid 
food  and  the  largest  proportion  of  milk. 

7.  The  normal  children  on  mixed  diet  retained  on  the  average  about 
94  per  cent  of  the  fat  intake,  regardless  of  the  type  of  stool.  The 
average  actual  retention  was  about  38  gm.  daily.  The  children  with 
little  or  no  solid  food  and  a  smaller  fat  intake  showed  a  lower  actual, 
and  a  somewhat  lower  percentage  retention  than  those  on  a  general 
mixed  diet. 

8.  The  rachitic  children  showed  a  slightly  larger  fat  loss  in  the 
stools  than  did  the  normal  children ;  their  intake,  however,  was  higher. 
Their  actual  retention,  therefore,  equalled  or  exceeded  that  of  the 
normal  children,  and  their  percentage  retention  was  only  a  little  lower 
than  the  normal  average. 


PREVENTION   AND    CONTROL   OF   DISEASE  41 

9.  The  fat  loss  in  the  stools  of  the  children  suffering  from  chronic 
intestinal  indigestion  was  very  great,  averaging  7.3  gm.  daily  in  the 
alkaline  stools  and  8.0  gm.  in  the  acid  stools.  Both  the  actual  and 
percentage  retention  were  much  lower  than  normal.  The  percentage 
of  the  intake  retained  averaged  79.1  when  the  stools  were  alkaline 
and  77.7  when  they  were  acid.  When  the  intake  of  fat  was  very  high 
the  actual  retention  was  usually  as  high  as  that  found  for  normal 
children. 

IV.  The  Digestion  of  Some  Vegetable  Fats  by  Children 
on  a  Mixed  Diet 

1.  The  stools  of  children  receiving  a  considerable  proportion  of 
vegetable  fat  did  not  differ  essentially  in  appearance  from  those  of 
children  receiving  mainly  milk  fat,  although  they  were  usually  some- 
what softer. 

2.  The  fat  percentage  of  dried  weight  of  the  stools  averaged  some- 
what lower  when  nut  butter  was  taken,  and  somewhat  higher  when 
corn  oil  was  taken,  than  when  the  fat  in  the  diet  was  mainly  milk  fat; 
and  when  large  quantities  of  corn  oil  were  included  in  the  diet  the 
average  was  much  higher. 

3.  The  soap  percentage  of  total  fat  in  the  stools  was  usually  a  little 
lower  and  the  neutral  fat  a  little  higher  with  vegetable  fat  than  when 
the  fat  of  the  diet  was  mainly  milk  fat. 

4.  When  nut  butter  was  taken  the  fat  excretion  in  the  alkaline 
stools  was  lower  and  in  the  acid  stools  it  was  higher,  than  when  the 
diet  did  not  contain  vegetable  fat.  When  corn  oil  was  taken  in  con- 
siderable amounts  the  fat  excretion  in  the  stools  was  higher  than  when 
the  fat  of  the  diet  was  mainly  milk  fat.  However,  the  total  fat  intake 
when  corn  oil  was  included  in  the  diet  was  very  large  and  the  actual 
retention  of  fat  always  much  higher  than  the  normal  average  for 
mixed  diet.  When  vegetable  fat  formed  a  considerable  part  of  the 
total  fat  intake,  the  percentage  of  the  fat  intake  retained  was  usually 
higher  than  the  normal  average.  In  a  few  instances  when  the  stools 
were  acid  and  in  a  few  when  large  amounts  of  corn  oil  were  taken, 
the  percentage  retained  was  low. 

5.  The  individual  children  observed  for  considerable  periods  with 
changes  in  the  kind  and  amount  of  fat  intake  showed  quite  as  good 
digestion  of  vegetable  fat  as  of  corresponding  amounts  of  milk  fat 
and  no  unfavorable  effect  on  general  health  and  nutrition  was  ob- 
served. No  children  were  kept  long  enough  on  a  diet  presumably  de- 
ficient in  fat-soluble  A  to  warrant  any  conclusions  as  to  the  effect  of 
such  a  diet  upon  growth  and  health.    In  the  case  of  one  child  who  for 


42 


DISEASES   OF    CHILDREN 


five  weeks  was  on  a  diet  in  which  there  was  no  definite  source  of  fat- 
soluble  vitamin,  95  per  cent  of  the  fat  of  the  diet  being  corn  oil,  he 
ceased  to  gain  in  weight,  but  showed  no  loss  and  the  general  health 
continued  excellent.  The  fact  may  not  be  without  significance  that  of 
six  children,  80  to  95  per  cent  of  whose  fat  intake  was  vegetable  fat, 
two  developed  styes  and  two  others  eczema  upon  the  face,  Avhich  dis- 
appeared when  the  diet  was  changed  to  include  milk  fat. 

Woman's  Milk  Feeding 

Woman's  milk*   is  a  highly  nutritious,   biologically  as   yet   some- 
what mysterious  product,   destined  by  nature   to  serve  as  the   food 


r/ 


Fig.  1. — Microscopic  appearances  of  woman's  milk.  (After  Fleischman.)  A. 
Poor  milk  showing  preponderance  of  large  fat  globules  and  a  paucity  of  fat.  B. 
Normal  milk,  showing  the  preponderance  of  medium-sized  fat  globules.  C.  Poor 
milk;  a  paucity  of  fat  and  an  almost  granular  state  of  the  fat  globules. 


*For   its   Approximate   Composition    see   footnote,    p.    48. 


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PREVENTION    AND    CONTROL   OF   DISEASE  43 

supply  alike  for  the  rich  and  the  poor,  the  weak  and  the  strong- 
infant  under  nine  months  of  age.  It  not  only  complies  with 
the  aforementioned  qualitative  requisites,  but  being  ready  for  imme- 
diate consumption — without  previous  pasteurization,  sterilization  or 
modification — at  all  hours  of  the  day  and  at  all  seasons  of  the  year,  it 
is  also  the  most  convenient  and  satisfactory  food  from  an  economic 
point  of  view.  Infants  reared  on  woman's  milk  are  almost  invariably 
healthier,  stronger  and  less  troublesome  than  those  that  are  bottle 
fed.  With  suitable  management  they  are,  as  a  rule,  free  from  gastro- 
enteric affections,  scurvy  and  rickets,  and  present  greater  power  of 
resistance  to  communicable  diseases. 

Maternal  Nursing. — For  the  reasons  just  given,  and  in  view  of  the 
facts  that  wet-nurses  are  expensive  luxuries,  are  often  unreliable,  and 
may  at  some  time  during  the  nursing  period,  through  unscrupulous 
and  impure  contact,  contract  and  convey  a  disease  to  her  charge,  it  is 
the  solemn  duty  of  every  healthy  mother  to  endeavor  to  nurse  her 
offspring,  wholly  or  partially,  even  if  it  be  only  for  a  brief  period  of 
time. 

Successful  maternal  nursing  presupposes,  in  addition  to  general  good 
health  of  the  mother,  well-developed  breasts  and  nipples  and  an  ample 
supply  of  milk.  These  qualifications  are  rarely  met  to  perfection  in 
women  of  large  cities,  where  the  extravagances  of  extreme  wealth  or 
the  misery  of  extreme  poverty  sap  their  vital  forces.  A  great  deal, 
however,  can  be  accomplished  by  judicious  management  of  the  mother 
during  pregnancy  and  parturition. 

The  prospective  mother  should  be  placed  in  the  most  healthful  physi- 
cal and  mental  condition.  Her  diet  should  be  liberal,  her  living  rooms 
spacious  and  airy  and  her  surroundings  cheerful.  She  is  to  be  free 
from  anxieties  of  a  livelihood  and  the  pompous  frivolities  of  wanton 
society.  The  primipara  should  be  taught  to  realize  that  pregnancy 
and  parturition  are  physiologic  processes,  ordinarily  devoid  of  peril- 
ous complications  or  sequelge. 

Toward  the  end  of  pregnancy  the  breast  nipples  should  be  elongated 
by  gentle  traction  Avith  the  fingers  or  pump,  and  cleansed  and  hardened 
by  means  of  hot  boric  acid  solutions,  cognac,  glycerite  of  tannin,  and 
the  like.  To  insure  an  ample  supply  of  breast  milk  after  delivery,  in 
addition  to  complying  with  the  aforementioned  suggestions,  a  liberal 
fluid  diet,  consisting  principally  of  rich  cow's  milk,  cornmeal  and  oat- 
meal gruel  cooked  in  milk,  malted  milk,  etc.,  forms  the  most  efficient 
adjuvant.  At  a  later  period  the  dietary  of  the  nursing  mother  should 
be  increased  by  a  liberal  allowance  of  meat,  eggs,  vegetables  and  other 
nutritious  foodstuffs  to  which  she  was  ordinarily  accustomed. 


44 


DISEASES  OF    CHILDREN 


Light  outdoor  exercise,  regulation  of  the  bowels,  avoidance  of  fa- 
tigue and  nerve  disturbances,  all  serve  well  to  improve  the  health  of  the 
mother  and  the  quality  of  her  milk  and  indirectly  to  promote  the  wel- 
fare of  the  baby. 

One  other  special  advantage  of  maternal-  over  wet-nursing  is  the 
benefit  the  newborn  derives  from  the  consumption  of  the  provisional 
milk  secretion — the  colostrum.  This  deep  yellow,  strongly  alkaline 
and  albuminous  fluid  which  forms  the  mammary  secretion  during  the 
first  three  or  four  days  after  labor,  not  only  acts  as  a  laxative — which 
is  badly  needed,  but  being  small  in  quantity  it  also  serves  to  moderate 
the  greedy  appetite  of  the  infant  and  prevents  early  overfeeding,  the 
usual  cause  of  infantile  colic. 

The  nursing  of  the  baby  is  generally  begun  about  eight  hours 
after  delivery,  or  later  if  the  mother  has  not  fully  recovered  from  the 
painful  and  fatiguing  ordeal.    During  the  first  few  days  the  infant  is 


Fig.  2. — Breast  pumps. 

applied  to  the  breast  every  three  or  four  hours  and  afterwards  every 
two  and  a  half  or  three  hours.  It  should  not  be  awakened  for  a 
feeding  if  sound  asleep  (except  when  very  weak  and  delicate),  and, 
unless  very  restless,  should  be  left  alone  from  10  p.  m.  to  5  a.  m.  It 
should  be  nursed  from  fifteen  to  twenty  minutes  at  a  time,  alternately 
on  one  and  the  other  breast,  or  on  both  breasts  if  the  milk  secretion 
is  scanty.  From  six  weeks  on  the  infant  should  be  fed  every  three 
hours,  and  less  frequently  when  it  reaches  six  months  of  age.  Between 
nursings  the  baby  may  receive  a  few  ounces  of  warm  water. 

Before  and  after  each  feeding  the  breast  nipples  should  be  carefully 
cleansed  with  a  warm  saturated  solution  of  boric  acid. 

If  the  breast  nipples  are  short,  sunken  or  cracked,  we  must  tempo- 
rarily resort  to  an  artificial  nipple  or  breast  pump  (Fig.  2).  The  lat- 
ter device  is  also  employed  where  the  infant  is  too  weak  to  pull,  or 
refuses  to  make  an  effort  to  do  so.    In  very  delicate  infants,  e.  g.,  pre- 


PREVENTION    AND    CONTROL    OF    DISEASE 


45 


matures,  it  is  often  necessary  to  withdraw  the  breast  milk  with  a  pump 
and  to  administer  it  by  means  of  a  spoon  or  dropper. 

With  the  suggestions  here  offered  the  majority  of  healthy  mothers 
will  be  able  to  nurse  their  offspring,  provided  they  are  sufficiently 
encouraged  by  the  physician  and  the  enormous  advantages  of  maternal 
breast  feeding  are  thoroughly  explained  to  them. 

When  an  infant  does  not  thrive  on  breast  milk,  it  is  imperative, 
before  resorting  to  another  infant  food,  to  analyze  carefully  the  breast 
milk,  and,  if  possible,  to  overcome  the  difficulty.    We  should  determine : 

1.  The  Quantity — This  can  readily  be  learned  by  extracting  the  milk 
supply  of  one  or  both  breasts,  or  by  weighing  the  infant  before  and  after 


Fig.  3. — Holt 's  milk  testing  apparatus. 


nursing  and  noting  the  difference  in  weight — the  gain  in  ounces  in- 
dicating the  amount  of  milk  it  has  obtained. 

2.  The  Quality. — As  the  sugar  is  usually  found  to  be  normal  in  all 
cases,  the  tests  are  ordinarily  limited  to  the  fat  and  protein  contents 
of  the  breast  milk.  After  obtaining  an  ounce  of  what  is  called  "middle- 
milk"  (i.  e.,  the  milk  collected  after  1  or  2  ounces  had  been  withdrawn) 
or  of  the  entire  breast  supply,  we  determine  the  following  qualifications : 

{a)  Reaction. — Fresh  breast  milk  should  be  alkaline  or  neutral  and 
may  be  tested  with  litmus  paper. 

(b)  Specific  Gravity. — This  should  be  about  1.030,  taken  by  means  of 
a  lactometer,  at  a  temperature  of  65°  to  72°  F. 

(c)  Fat  Content.— The  cylinder  of  Holt's  milk  set  (Fig.  3)  is  filled 
with  the  sample  of  breast  milk  up  to  the  zero  mark  and  allowed  to 


46 


DISEASES   OF    CHILDREN 


stand  for  twenty-four  hours  in  a  room  temperature  of  70°  F.  The  per- 
centage of  cream  is  then  read  off,  bearing  in  mind  that  the  ratio  of  the 
cream  to  the  fat  is  approximately  5  to  3,  i.  e.,  5  per  cent  of  cream  equals 
3  per  cent  of  fat. 

(d)  Proteids. — The  amount  of  proteids  is  approximately  determined 
by  the  amount  of  fat  and  the  specific  gravity  of  the  milk,  i.  e.,  high  spe- 
cific gravity,  high  proteids;  low  specific  gravity,  high  fat.  Holt's  accom- 
panying table  explains  the  application  of  this  principle: 


Specific 
Gravity 


Cream 
(24  Hours) 


Proteid 
(Calculated) 


Average 

Normal  variations 
Normal  variations 
Abnormal    variations 

Abnormal    variations 

Abnormal    variations 

Abnormal    variations 


1.031 

1.028-1.029 

1.032 

Low  (below  1.028) 

Low  (below  1.028) 

High  (above  1.032) 

High  (above  1.032) 


8%-12% 

5% -6% 

High  (above  10%) 

Low    (below  5%) 

High 

Low 


1.5% 
Normal    (rich   milk) 
Normal    (fair  milk) 
Normal  or  slightly 

below 
Very  low   (very  poor 

milk) 
Very  high   (very  rich 

milk) 
Normal  (or  nearly  so) 


While,  as  a  rule,  the  breast  milk  of  the  modern  mother  is  characteristic 
for  its  paucity,  we  occasionally  come  across  breast  milk  that  is  too  rich 
in  quality,  especially  as  regards  the  fat  content.  In  the  majority  of 
such  instances,  if  the  excess  in  fat  is  detected  early,  it  can  readily  be 
corrected  (by  reducing  the  mother's  diet,  encouragement  of  active 
exercise,  etc.,  or  by  resorting  to  partial  nursing)  before  any  appreciable 
harm  has  been  done  to  the  infant.  In  some  cases,  however,  the  abnor- 
mality of  the  milk  is  not  discovered  until  the  infant  is  suffering  from 
"fat  indigestion"  (diarrhea  with  curds  of  fat,  eructations,  colic  and 
possibly  loss  of  weight),  and  one  is  often  in  a  quandary  as  to  what  is 
best  to  do.  An  attempt  may  be  made  to  thin  the  breast  milk  by  admin- 
istering to  the  infant  before  each  nursing  I/2  or  1  ounce  of  plain  or 
cereal  water.  Or  the  baby  is  allowed  to  nurse  at  the  breast  only  a  few 
minutes  and  is  then  given  an  ounce  or  two  of  diluted  skimmed  milk  to 
make  up  the  quantity  to  satisfy  the  baby.  If  these  procedures  and  the 
dieting  of  the  mother  fail,  and  the  child  is  progressively  getting  worse, 
we  must  either  engage  a  wet-nurse  or  put  the  baby  on  a  suitable  artificial 
food. 

Where  the  milk  supply  is  deficient,  partial  nursing  should  be  insisted 
upon,  preferably  alternating  one  breast-  with  one  bottle-feeding. 

Wet-Nursing. — Wet-nurses  at  best  are  an  evil,  but  often  indispen- 
sable, where  mothers  will  not,  cannot,  or  must  not  nurse  their  own  off- 
spring. If  the  mother  cannot  nurse  her  baby  because  of  quantitative 
or  qualitative  insufficiency  of  her  milk,  there  is  no  urgency  of  securing 


PREVENTION    AND    CONTROL   OF    DISEASE  47 

a  wet-nurse,  as  the  milk  may  be  improved  bj'  a  richer  diet  and  better 
care  of  the  mother,  or  the  infant  may  receive  daily  two  or  three  feed- 
ings of  properly  modified  cow's  milk.  In  the  event,  however,  that  the 
mother  is  utterly  unable  to  nurse  her  baby  or  is  prevented  from  doing 
it  through  disease  (tuberculosis,  cancer;  acute,  greatly  debilitating  af- 
fections ;  advanced  kidney  or  heart  disease ;  local  inflammation  of  the 
breast,  psychoses  and  the  like)  or  pregnancy,  a  wet-nurse  is  the  best 
substitute.  The  wet-nurse  to  be  chosen  must  undergo  a  very  careful 
physical  examination,  first  as  to  the  secreting  quality  of  the  breasts 
and  the  condition  of  the  nipples,  and  next  as  to  her  general  health. 

The  secreting  quality  of  the  breast  is  best  tested  by  "stripping," 
i.e.,  by  grasping  the  upper  portion  of  the  nipple  with  the  thumb  and  two 
fingers,  and,  while  moving  the  fingers  briskly  forward,  exerting  uni- 
form but  gentle  pressure.  With  this  manipulation  the  milk  should 
escape  from  the  breast  in  several  even  jets  for  from  fifteen  to  thirty 
seconds.  Too  much  reliance  should  not  be  placed  upon  the  form  of 
the  breast,  for  even  pendulous,  cylindrical,  or  conical  breasts  are  occa- 
sionally poor  milk  producers.  On  the  other  hand,  an  abundance  of 
glandular  parenchyma  offers  more  reliable  guarantee  as  to  its  secreting 
power.  The  physician  should  be  on  his  guard  that  the  abundance  of 
milk  be  not  the  result  of  the  breast  having  been  allowed  to  fill  up  for 
several  hours  previous  to  the  examination — a  fact  recognized  by  the 
presence  of  pain  on  pressure  and  intense  distention  of  the  mammary 
ducts.  The  nipples  should  be  hard,  long  and  bulky,  free  from  severe 
erosions  or  fissures. 

The  quality  of  the  milk  is  not  nearly  as  essential  as  the  quantity, 
since  the  former  can  usually  be  improved  upon  by  suitable  diet  and 
good  hygiene.  •• 

The  following  diseases  render  a  wet-nurse  useless:  Tuberculosis, 
whether  local  or  general;  syphilis,  in  all  its  stages  (not  necessarily  con- 
traindicated  in  the  mother)  ;  noncompensating  heart  disease;  grave  af- 
fections of  all  other  bodily  organs ;  profound  anemia ;  intractable, 
communicable  skin,  hair,  and  eye  diseases ;  gonorrhea ;  suppurative 
processes  of  the  bones;  mastitis  (not  necessarily  contraindicated  in  the 
mother) ;  ozena,  drug  addiction,  psychoses,  and  epilepsy. 

The  possible  presence  of  syphilis  should  receive  special  attention. 
Corona  veneris,  bony  tumefactions,  nasopharyngeal  patches,  old  ulcers 
and  scars,  enlarged  glands  (especially  paramammary,  epitrochlear,  and 
inguinal)  should  invariably  arouse  the  suspicion  of  the  examiner.  Ev- 
ery wet-nurse  should  undergo  a  Wassermann  test. 

The  wet-nurse  of  choice  should  be  one  between  twenty  and  thirty 
years,  who  has  given  birth  to  two  healthy  children  and  nursed  one  sue- 


48  DISEASES   OF    CHILDREN 

eessfully,  the  age  of  the  last  child  being  nearly  the  same  as  the  one 
she  is  about  to  nurse.  The  diet  of  the  wet-nurse,  the  care  of  her  breasts 
and  nipples,  the  mode  of  living,  exercise,  etc.,  should  be  the  same  as  in 
a  nursing  mother  (q.  v.).  Sudden  changes,  however,  from  dire  want  to 
superabundance  are  to  be  avoided. 

Artificial  Feeding 

Where  maternal  nursing  is  impossible,  and  wet-nursing  impracti- 
cable, there  is  nothing  else  left  but  to  resort  to  artificial  feeding.  All 
human  ingenuity  and  skill  have  thus  far  failed  to  provide  a  food  for 
infants  that  is  as  nutritious,  digestible,  sterile  without  interference 
of  composition,  and  as  economic  as  woman's  milk. 

Cow's  Milk  Feeding- 

"With  suitable  modification  cow's  milk  forms  the  best  substitute 
for  human  milk.  But  it  is  a  poor  substitute  at  best,  for  not  alone 
does  human  milk  vastly  differ  from  cow's  milk  in  the  quantitative  pro- 
portion of  the  essential  chemical  ingredients,  but  the  latter  vary 
greatly  also  qualitatively.  Furthermore,  human  milk  contains  several 
as  yet  not  fully  determined  biologic  constituents,  especially  enzymes, 
which  are  absent  in  cow's  milk. 

To  meet  the  aforementioned  requirements  of  an  infant  food,  cow's 
milk  must  undergo  considerable  modification  to  approach  human 
milk  in  its  composition.  As  may  be  noted  from  the  comparative 
table*  of  human  and  cow's  milk,  the  latter  contains  about  five  times 
as  much  of  casein  and  only  half  as  much  of  lactalbumin  as  the  former. 
Cow's  milk-casein  coagulates  in  the  stomach  in  large  firm  curds  which 
dissolve  slowly,  the  opposite  being  the  case  with  human  milk-casein. 
Human  milk-fat  forms  a  finer  emulsion  than  cow's  milk-fat,  and  con- 
tains a  much  smaller  amount  of  fatty  acids.  The  salt  in  human  milk 
is  richer  in  iron  and,  finally,  human  milk  is  sterile,  whereas  cow's 
milk  when  reaching  the  consumer  is  replete  with  bacteria. 

To  equalize  the  numerous  differences  between  the  two  milks,  so  as 
to  render  cow's  milk  both  digestible  and  nutritious,  we  have  to  pro- 
ceed as  follows: 

1.  Reduce  the  quantity  and  coagulability  of  the  casein  by : 

♦Approximate   Composition   of   Human   and   Cow's   Milk: 

Human  Cow's 

Water    87  88 

Solids     13  12 

Caloric   value    750  .650 

Lactalbumin    qnd    g-lobulin     0.7S   to    1  0.3   to    O.S 

Casein   (combined  with  calcium)    0.5  to   0.75  3.0 

Fat   4.0  to   4.5  3.5  to   4.0 

Milk  sugar 7.0  4.0  to   4.5 

Salts     0.20  0.7 


PEEVENTION    AND    CONTROL    OF    DISEASE  49 

(a)  Dilution ;  adding,  for  example,  to  1  ounce  of  cow's  milk  2  ounces  of 
either  plain,  or  cereal  water,  a  milk  mixture  is  obtained  containing  but  1 
per  cent  of  protein,  which  can  readily  be  assimilated  by  a  young  infant. 
Although  it  has  recently  been  claimed  that  normal  babies  can  tolerate 
large  amounts  of  cow's  milk-casein,  we  must  be  cautious  to  accept  these 
views  as  final,  since  the  medical  profession  has  lately  been  swayed  too 
often  from  one  extreme  view  to  the  other.  Lime  water  is  usually  added, 
by  its  alkalinity,  to  delay  the  coagulation  of  the  casein ;  and  cereal  diluents 
act  both  as  a  food  and  protective  colloids  which  hinder  the  formation  of 
large  casein  curds.  Starches  in  large  quantities,  however,  are  not  very 
readily  digested  by  infants  under  two  or  three  months  of  age. 

(&)  Addition  of  sodium  citrate,  1  to  2  grains  to  every  ounce  of  milk 
or  cream.  Sodium  citrate  acts  by  combining  with  calcium  caseinate  of 
the  milk  to  form  calcium  citrate  and  sodium  caseinate,  which,  after  being 
split  up  by  the  rennin,  changes  into  soluble  sodium  paracaseinate. 

(c)  Boiling  the  milk  for  five  minutes  in  a  single  boiler. 

(d)  Peptonization  (p.  59). 

2.  Increase  the  sugar  (which  has  become  reduced  in  quantity  by  dilu- 
tion) by  the  addition  of  either  milk  sugar,  malt  sugar  or  cane  sugar, 
the  quantity  varying  with  the  degree  of  dilution  of  the  milk  mixture. 
Ordinarily  one-half  of  a  teaspoonful  for  each  ounce  of  the  diluent*  will 
be  required.  There  is  still  considerable  divergence  of  opinion  as  to 
which  of  disaccharides  are  best  suited  for  infant  feeding.  I  am  inclined 
to  think  that  milk  sugar  probably  serves  best  for  normal  babies,  while 
maltose  or  dextrimaltose  is  best  in  digestive  disturbances.  Cane  sugar 
is  more  useful  in  constipation. 

3.  Augment  the  fat  content,  if  diminished  by  dilution  of  the  milk,  by 
the  addition  of  gravity  cream  (the  cream  that  is  visible  on  bottle  milk 
after  setting  for  six  hours  or  longer)  or  preferably  by  using  "top  milk"f 


♦Mode  of  Preparation  of  Diluents  for  Cow's  Milk. — Barley  water. — One  tablespoonful  of 
prepared  barley  (Robinson's)  is  rubbed  up  in  a  little  cold  water;  to  this  is  gradually  added  a 
quart  of  boiling-hot  water,  and  the  mixture  is  allowed  to  boil  slowly  (simmer),  with  constant 
stirring,  for  about  twenty  minutes  and  then  strained.  Boiled  water  is  then  added  sufficient 
to    make    one    quart.      Ground   grnats    is    especially    useful    in    constipation. 

Oatmeal  water. — One  tablespoonful  of  oatmeal  is  rubbed  up  in  a  little  cold  water;  to  this 
is  added  a  pint  of  boiling-hot  water  and  allowed  to  boil  slowly  (simmer)  for  one  to  two  hours, 
with  frequent  stirring,  and  strained  through  gauze.  Boiled  water  is  then  added  sufficient  to 
make  one  pint. 

Rice  water. — One  tablespoonful  of  ground  rice  to  a  quart  of  water,  prepared  the  same  as 
barley   water. 

I        tTop   milk. — Bottle   milk,   as   obtained    from   reliable    milk   dealers,    contains   approximately    the 
following  percentages  of  fat  and  proteids  : 
Portion  Taken 
Upper   J/i    ounce 
1 
2 
4 

6  " 

8  " 

12  " 

"        16  " 

"       18  " 


Fat 

Pkoteids 

24.8 

3.1 

23.1 

3.2 

21.4 

i.3 

20.1 

3.4 

18.6 

3.5 

16.7 

Z.6 

12.1 

Z.7 

8.4 

3.8 

6.5 

3.9 

50 


DISEASES   OP    CHILDKEN 


as  a  base,  i.  e.,  by  taking  instead  of  ' '  whole ' '  milk  a  sufficient  amount  of 
milk  of  the  upper  18  ounces  of  a  bottle  (which  contains  6.5  per  cent  of 
fat)  decanted  for  this  purpose  and  thoroughly  mixed  (Fig.  4). 

4,  Insure  the  absence  of  pathogenic  bacteria  in  cow's  milk  by  ob- 
serving the  following  suggestions : 

The  cow  must  be  free  from  disease,  especially  from  tuberculosis 
as  determined  by  the  tuberculin  test  and  by  regular  inspection  by  a 
competent  veterinary  surgeon. 

The  cow's  entire  body  should  be  groomed  daily  and,  immediately 
before  milking,  the  belly,  tail,  and  particularly  the  udder  should  be 
carefully  cleansed  with  a  clean,  damp  cloth,  with  or  without  soap, 
and  dried  with  a  clean  towel. 

The  milker  must  be  free  from  communicable  affections.  Before 
milking,  he  should  thoroughly  scrub  and  dry  his  hands  and  don  clean 


Fig.  4. — Chapin's  dipper  for  removal  of  "top-milk". 

washable,  outer  garments.  He  should  have  a  few  of  these  on  hand, 
in  order  to  change  them  should  one  gown  or  suit  accidentally  get 
soiled  in  the  act  of  milking. 

The  milk  of  each  cow  should  be  collected  separately  in  sterile 
utensils  and  immediately  removed  from  the  stable  to  a  clean  place 
specially  reserved  for  the  keeping  of  the  milk  until  ready  for  shipment. 

The  milk  should  be  rapidly  cooled  (below  45°  F.)  and  strained 
through  a  sterile  strainer,  then  bottled,  closed  with  sterile  discs,  capped, 
and  finally  iced — all  within  an  hour  or  so  after  milking. 

Owing  to  the  rapid  development  of  bacteria  in  milk  over  twenty- 
four  hours  old,  the  milk  should  reach  the  consumer  within  this  pe- 


PREVENTION   AND    CONTROL    OF    DISEASE   "  >       >  5  J 

riod  of  time.     The  milk  should  further  be  }%(i^\  on,  ice  witil  i^eeded 
for  the  preparation  of  the  food. 

If,  notwithstanding  all  the  prophylactic  measures,  some  doubt  still 
remains  as  to  the  sterility  of  the  milk,  we  must  subject  it  to  steriliza- 
tion or  pasteurization.* 

Laboratory  and  Home  Modification  of  Cow's  Milk 

We  have  just  learned  the  numerous  essential  differences  of  com- 
position that  exist  between  human  and  cow's  milk,  and  the  means  by 
which  the  differences  can  be  removed.  Were  it  merely  a  question  of 
obtaining  milk  of  a  definite  uniform  composition  which  would  at  once 
prove  suitable  for  the  feeding  of  infants  of  all  ages,  the  problem  of 
artificial  feeding  of  infants  would  long  have  been  solved.  Unfor- 
tunately this  is  not  the  case.  Not  only  must  cow's  milk  be  modified  so 
that  its  principal  constituents  greatly  resemble  those  of  human  milk, 
but  it  must  undergo  also  specific  modification  to  meet  the  digestive 
powers  and  the  requirements  of  the  individual  infant  at  certain  periods 
of  life — quite   a   difficult   proposition  indeed. 

Thanks  to  the  rapid  strides  of  physiologic  chemistry  and  the  good 
will  and  enterprise  of  several  milk  dealers  and  laboratory  chemists, 
the  modification  of  cow's  milk  as  an  infant  food  has  almost  reached 
a  stage  of  perfection.  With  the  help  of  the  laboratory  chemist,  the 
physician  is  now  enabled  to  write  a  prescription  for  a  food  mixture 
of  definite  composition  and,  like  a  drug  in  the  pharmacy,  have  it  com- 
pounded exactly  as  ordered.  The  latitude  of  composition  is  well  illus- 
trated in  the  prescription  form  on  page  52.f 

When  "laboratory  milk"  is  not  obtainable,  and  "home  modifica- 
tion" has  to  be  resorted  to,  we  may  greatly  facilitate  the  process  and 
obviate  the  difficult  task  of  memorizing  complicated  formulas  by  se- 


*Sterilization  and  Pasteurization. — Both  of  these  processes  are  accomplished  by  means  of 
one  of  the  many  sterilizers  on  the  market.  In  sterilizing,  the  milk  is  heated  for  about  fifteen 
minutes  at  a  temperature  of  212°  F. ;  in  pasteurizing,  for  about  forty  minutes  at  a  temperature 
of  from  140°  to  150°  F.  For  infant-feeding  the  milk  should  undergo  the  heating  process  after 
it  has  been  modified  and  divided  in  the  requisite  number  of  feeding  bottles  for  the  entire 
twenty-four  hours.  The  bottles  are  cooled  off  by  allowing  cold  water  slowly  to  run  through 
the  sterilizer;  they  are  then  tightly  corked,  preferably  with  nonabsorbent  cotton,  and  placed  on 
ice  until  needed  for  use.  Before  feeding  the  bottle  should  be  warmed  to  body  heat.  Except 
during  the  hot  summer  months  or  when  there  is  good  reason  to  believe  that  the  milk  harbors 
virulent  bacteria  {e.g.,  during  epidemics  of  typhoid,  cholera,  etc.),  sterilization  is  nowadays 
rarely  practiced.  Pasteurization  is  usually  resorted  to  instead,  particularly  since  it  has  been 
demonstrated  that  this  process  is  less  apt  to  change  the  taste  of  the  milk,  to  interfere  with  its 
digestibility,  or  to  cause  constipation.  The  view  held,  especially  by  overenthusiastic,  though 
well-meaning,  laymen,  that  pasteurized  milk  is  as  nutritious  as  clean,  fresh,  raw  cow's  milk, 
is  not  based  upon  scientific  observation.  Quite  the  contrary ;  pasteurized  milk  lacks  several 
nutritive  and  protective  elements  that  exist  in  fresh  cow's  milk.  Hence,  its  continued  use 
greatly  interferes  with  the  growth  and  development  of  the  infant,  and  is  not  rarely  productive 
of  rickets  and   scurvy,  if   the   baby  is  fed  on   milk   exclusively. 

tFrom   Morse  and  Talbot's  "Diseases  of  Nutrition." 


52    TO  \TV/A«61J 

'r^vkQ:::::: 


DISEASES   OF   CHILDREN 


Per   Cent 


(a)   Carbohydrates. 


Lactose    (milk   sugar) 
Maltose    (malt   sugar) 
Sucrose    (cane   sugar) 
Dextrose   (grape  sugar) 
Starch 


(&)   Dextrinizo 

/   N   T,     i  •      f  Whey.  , 

(c)  Proteins  I  ^^^J^^_ 

(d)  F'eptonizc 

(e)  Sodium  citrate 


f  %   of   milk   and   cream. 
\  %   of  total  mixture .  . .  , 


%  of  milk  and  cream. 
%   of  total  mixture .  . , 


%  of  milk  and  cream. 
%   of  total  mixture .  .  . 


(/)   Sodium  bicarb 

(g)  Lime  water 

,,,    T      J.-        -lu     -11      r  1.  To  inhibit  the  saprophytes  of  formentaticn_. 
(;0   Lactic  acid  bacillus  I  2_  ^^  facilitate  digestion  of  the  proteins 

Heat  at °  F.     Number  of  feedings Amount  of  each  feeding. 

Ordered  for 

Date 


.M.D. 


EXPLANATOEY 

(a)   It  requires  0.75  per  cent  starch  to  make  the  precipitated  casein  finer. 

(h)   One  hour  completely  dextrinizes  the  starch. 

(c)  In  case  physicians  do  not  wish  to  subdivide  the  proteins,  the  words  "whey" 
and  ' '  casein ' '  may  be  erased. 

{d)   Twenty  minutes  render  the  mixture  decidedly  bitter. 

(e)  It  requires  0.29  per  cent  of  the  milk  and  cream  used  in  modifying  to  facilitate 
the  digestion  of  the  proteins;  i.e.,  the  formation  of  a  soft  curd;  0.40  per  cent  to  pre- 
vent the  action  of  rennet;  i.e.,  the  formation  of  tough  curds. 

(/)  It  reqtSfires  0:68  per  cent  of  the  milk  and  cream  used  in  modifying  to  favor 
the  digestion  of  the  proteins;  1.70  per  cent  of  the  amount  of  milk  and  cream  used 
suspends  all  action  on  the  proteins  in  the  stomach;  0.17  i)er  cent  of  the  total  mix- 
ture gives  a  mild  alkaline  food. 

(g)  It  requires  20  per  cent  of  the  milk  and  cream  used  in  modifying  to  favor  the 
digestion  of  the  proteins;  50  per  cent  of  the  amount  of  milk  and  cream  used  sus- 
pends all  action  on  the  proteins  in  the  stomach.  I'ive  per  cent  of  the  total  mixture 
gives  a  mild  alkaline  food. 

(h)  Percentage  figures  represent  the  per  cent  of  lactic  acid  attained  Avhen  the  food 
is  removed  from  tlie  thermostat.  When  the  lactic,  acid  bacillus  is  used  to  facilitate 
the"  digestion  of  the  proteins,  this  is  the  final  acidity,  as  the  process  is  stopped  by 
heat  at  this  i^oint.  When  the  bacillus  is  used  to  inhibit  the  growth  of  saprophytes 
the  acidity  may  subsequently  increase  to  a  variable  degree,  as  the  bacilli  are  left 
alive;  0.25  per  cent  lactic  acid  just  curdles  milk;  0.50  per  cent  gives  thick  curdled 
milk;  0.75  per  cent  separates  into  curds  and  Avhey. 

lecting  a  "standard"  milk  formula  of  simplest  composition  (1:1,  i.e., 
1  ounce  or  its  multiple  of  milk  to  1  ounce  or  its  multiple  of  a  diluent) 
and  preparing  the  other  milk  mixtures  by  modifying  this  "standard" 
formula. 


PREVENTION    AND    CONTROL   OF   DISEASE  53 

Directions. — 1.  Bear  in  mind  the  standard  formula  (1:1),  which  is 
intended  for  an  infant  three  months  old. 

2.  For  infants  under  three  months  increase  about  every  month  down- 
ward the  diluent  by  1  ounce  or  its  multiple,  using  "top  milk"  (upper 
18  ounces)  as  a  base  and  plain  water  as  the  diluent. 

3.  For  infants  over  three  months  of  age,  increase  every  two  months 
upward  the  milk  by  1  ounce  or  its  multiple,  using  "whole  milk"  as 
a  base  and  cereal  water  as  a  diluent. 

4.  Add  to  each  ounce  of  the  diluent  from  Y^  to  i/^  teaspoonful  of  sugar 
(milk,  malt  or  cane  sugar)  and  1  teaspoonful  of  lime  water. 


1:5 

2:1 

one  week 

five  months 

1:4 

3:1 

two  weeks 

Standard    Formula 
milk   1:1    diluent 

seven  months 

1:3 

three  months 

4:1 

one  month 

nine  months 

1:2 

5:1 

;wo  months 

eleven  months 

Milk  modified  in  accordance  with  these  suggestions  yields  milk  mix- 
tures of  the  following  approximate  composition : 

For   an   infant   one   week   old    (1:5). 

Top  milk 2-2/3  ounces         Proteins    0.50 

Lime  water 3  drams  Sugar    6.00 

Water 13  ounces         Fat    1.00 

Sugar 4-1/3  drams 

Divide  in  8  bottles;  give  a  feeding  every  three  hours  during  the  day  and  night,  if 
the  baby  is  awake. 

For  an  infant  two  weeks  old    (1:4). 

Top  milk 4  ounces         Proteins    0.6 

Lime  water 1/2  ounce  Sugar 6.00 

Water 15-1/2  ounces         Fat    1.20 

Sugar 2'/3  ounce 

Divide  in  8  bottles;  give  a  feeding  every  three  hours  during  the  day  and  night,  if 
the  baby  is  awake. 

For  an  infant  one  month  old   (1:2). 

Top  milk 6-1/2  ounces         Proteins    0.75 

Lirne  water 3/4  ounce  Sugar    6.00 

AVater 17-1/2  ounces         Fat    1.50 

Sugar 3/4  ounce 

Divide  in  7  bottles;  give  a  feeding  every  three  hours  during  the  day  and  night,  if 
the  baby  is  awake. 

For  an  infant  two  months  old   (1:3). 

Top  milk 10  ounces         Proteins    1.00 

Lime  water 1-1/4  ounces         Sugar    6.00 

Water 19  ounces         Fat    2.00 

Sugar.  . 7/8  ounce 

Divide  in  7  bottles;   give  a  feeding  every  three  hours  during  the  day,  and  once 
during  the  night  if  the  baby  is  awake. 


54  DISEASES   OF    CHILDREN     • 

For  an  infant  three  months  old   (1:1). 

Whole  milk 18  ounces         Proteins    1.50 

Lime  water 2-1/4  ounces         Su^ar    6.00 

Barley  Avater 16  ounces         Fat    2.00 

Sugar 2/3  ounce 

Divide  in  7  bottles;  give  a  feeding  every  three  hours  during  the  day,  and  once 
during  the  night  if  the  baby  is  awake. 

For  an   infant  five   months   old    (2:1). 

Whole  milk ;  26  ounces         Proteins    2.00 

Lime  water 3-1/4  ounces         Sugar    6.00 

Barley  water 10  ounces         Fat    2.60 

Sugar 1/2  ounce 

Divide  in  6  bottles;  give  a  feeding  every  three  hours. 

For  an  infant  seven  months  old   (2:1). 

Whole  milk 32"  ounces         Proteins    2.25 

Lime  water 4  ounces         Sugar    6.00 

Barley  water 7  ounces         Fat    3.00 

Sugar 1/2  ounce 

Divide  in  6  bottles;  give  a  feeding  every  three  hours. 

For  an  infant  nine  months  old   (4:1). 

Whole  milk 34  ounces         Proteins    2.45 

Lime  water 4-1/2  ounces         Sugar    6.00 

Barley  water  (concentrated) ...  4  ounces         Fat    3.25 

Sugar 1/3  ounce 

Divide  in  5  bottles;   give  a  feeding  every  four  hours. 

For  an  infant  eleven   months   old    (5:1). 

Whole  milk 37-1/2  ounces         Proteins    2.50 

Lime  water 4-3/4  ounces         Sugar 6.00 

Barley  water  (concentrated) ...  3  ounces        Fat    3.50 

Sugar 1/4  ounce 

Divide  in  5  bottles;   give  a  feeding  every  four  hours. 

For  infants  over  a  year,  give  undiluted  whole  milk. 

The  method  of  home  modification  of  milk  here  described,  while 
not  very  exact,  is  based  upon  clinical  experience,  and  has  the  further 
advantage  over  many  other  methods  in  vogue  in  that  it  does  not  re- 
quire the  knowledge  of  higher  mathematics  for  its  calculation.  In- 
fant feeding  by  calories,  while  very  ingenious,  is  hardly  applicable 
in  the  feeding  of  infants  under  three  or  even  six  months  of  age,  since 
it  provides  amounts  of  fat  or  protein  often  entirely  beyond  the  in- 
fantile digestive  capacity.  According  to  Heubner*  an  infant  requires 
a  daily  ration  of  about  45  calories  for  every  pound  of  its  weight  dur- 
ing the  first  quarter  of  a  year ;  40  calories  during  the  second  quarter ; 
35  during  the  third ;  and  30  during  the  fourth  quarter.  Fifteen  grains 
(1  gram)  of  protein  or  carbohydrates  furnish  4.1  calories  and  15  grains 
of  fat,  9.3  calories ;  or  1  ounce  of  whole  milk,  20  calories.    Taking  for 


*Both   ITeubner's   and   Budin's   suggestions  work   well   in   breast   feeding. 


PLATE   II 

Formed  Alkaline  Stools 

A  marked  example  of  the  formed,  alkaline  stools,  consisting  largely  of  soaps, 
sometimes  found  in  feeding  with  cow's  milk,  without  excess  of  fat;  or  with  "pro- 
tein" milk.  They  arc  associated  with  increased  putrefaction  but  diminished  fer- 
mentation in  the  intestinal  canal. 

(Courtesy    Dr.    Hector    Charles    Cameron.) 


PREVENTION    AND    CONTROL   OF   DISEASE  55 

example  an  infant  one  month  old,  ordinarily  weighing  8  pounds,  it 
would  require  in  twenty-four  hours,  8  x  45  =  360  calories,  i.  e.,  either 
18  ounces  of  whole  milk,  which  would  be  entirely  too  rich  in  casein 
for  an  infant  of  that  age,  or  4I/2  ounces  of  gravity  cream  greatly  di- 
luted, which  would  be  too  rich  in  fat  and  too  poor  in  protein  and  sugar. 
The  same  fault  is  to  be  found  in  Budin's  method  of  giving  daily  an 
amount  of  milk  equal  to  10  per  cent  of  the  body  weight  of  the  baby. 

The  keynote  of  successful  artificial  feeding  is  individualization, 
*.  e.,  the  selection  of  a  food  in  proper  proportions  as  to  fat,  sugar,  and 
protein  suitable  for  each  individual  baby's  power  of  digestion  and  as- 
similation, and  in  sufficient  quantities.  The  amount  of  food  needed 
by  the  healthy  infant  is  best  judged  by  the  capacity  of  the  stomach*, 
subject,  of  course,  to  variations  as  to  size,  activity,  etc.  The  question 
of  the  proportion  of  the  food  elements  must  be  decided  from  time  to 
time  in  each  individual  case,  after  considering  the  gain  or  loss  in 
weight  under  the  respective  food,  and  watching  the  consistency,  etc., 
of  the  bowel  movements. 

Indications  of  Faulty  Assimilation  of  the  Food 

All  disturbances  of  digestion,  be  they  due  to  an  excess  of  protein, 
sugar,  or  fat,  have  several  symptoms  in  common,  thus:  Restlessness, 
flatulence,  colic,  loss  in  weight,  frequent  defecations  and  vomiting; 
in  acute  indigestion  also  moderate  or  high  fever.  To  determine 
whether  the  digestion  of  fat,  sugar,  or  protein  is  at  fault,  we  have  to 
examine  the  vomitus  and  feces. 

In  fat  digestion,  the  stools  are  either  soft  (containing  soft  curds) 
and  oily  in  appearance  or  of  a  creamy  consistence,  or,  especially  in 
cases  of  long  duration,  gray  or  grayish  yellow,  hard  and  dry,  forming 
the  so-called  ''soap-stools."  Sometimes  the  stools  are  watery,  strongly 
acid,  causing  severe  irritation  of  the  buttocks.  The  vomitus  is  also 
strongly  acid.     The  lips  are  often  cherry-red  in  color. 

In  sugar  indigestion  vomiting  is  less  common  than  in  fat  indigestion, 
but  if  it  does  occur,  the  vomitus,  like  the  feces,  is  acid  in  reaction  and 
often  presents  the  characteristic  odors  of  lactic,  acetic  or  succinic 
acid.  The  stools  are  usually  thin,  often  mixed  with  mucus,  light  or 
dark  green,  and  very  irritating  to  the  buttocks.  In  severe  cases  there 
may  be  high  fever,  with  other  symptoms  of  acute  intoxication. 

Starch  indigestion  may  give  rise  to  loose,  brown  stools,  mixed  with 


*The  following  fairly  represents  the  average  capacity  of  the  infantile  stomach:  At  the 
end  of  the  first  week,  1  ounce;  the  second  week,  2  ounces;  first  month,  3  ounces;  second  month, 
4  ounces;  fourth  month,  5  ounces;  sixth  month,  6  ounces;  eighth  month,  7  ounces;  tenth  month, 
8  ounces;  twelfth  month,  9  ounces;  fourteenth  month,  10  ounces. 


56  DISEASES   OF    CHILDREN 

mucus,  changing  into  blue  color  on  addition  of  iodine.  Infants  fed 
exclusively  on  starch  food  slowly  develop  athrepsia. 

An  excess  of  casein  usually  gives  rise  to  large,  often  tough,  curds  in 
the  vomitus  and  stools,  neutral  or  slightly  acid  in  reaction  and  free 
from  any  characteristic  odor.  In  some  cases  the  stools  are  loose,  mu- 
cous, brown  in  color,  and  musty  in  odor. 

The  management  of  the  aforementioned  digestive  disturbances,  in 
a  way,  is  self-evident:  we  have  to  reduce  temporarily  the  offending 
food  element  in  the  infant's  diet,  which  must  either  be  reduced  in 
quantity  or  eliminated  entirely.  Skimmed  milk  and  cereals  should 
be  given  in  fat  indigestion :  diluted  skimmed  milk  or  Eiweissmilch  in 
carbohydrate  indigestion;  or  condensed  milk,  well-diluted  boiled  milk, 
or  weak  mixtures  of  Eiweissmilch  with  the  addition  of  malt  dextrin  in 
digestive  disturbances  due  to  an  excess  of  protein.  Of  course,  with  dis- 
appearance of  the  symptoms  the  required  fat,  carbohydrate-  and  pro- 
tein-proportions of  the  food  are  gradually  to  be  resumed.  (See  also 
''Dyspepsia"  and  "Acidosis.") 

Cow's  Milk  Substitutes 

Malt  Soup. — Two  ounces  of  wheat-flour  are  slowly  and  thoroughly 
mixed  with  one  pint  of  milk,  and  strained  through  gauze.  In  a  second 
vessel  3  ounces  of  thick  malt  are  dissolved  in  a  quart  of  warm  water 
to  which  had  been  added  15  grains  of  carbonate  of  potassium.*  Now 
both  solutions  are  mixed  together  and  heated  very  slowly  up  to  a  boil. 
As  the  children  improve  the  water  may  gradually  be  reduced  to  a 
pint.  Malt  soup  is  often  particularly  beneficial  in  underfed,  dyspep- 
tic and  rachitic  babies.  If  well  tolerated  it  may  be  continued  for  sev- 
eral months. 

It  is  advisable,  however,  gradually  to  replace  the  malt  soup  by  or- 
dinary milk  mixtures,  and  other  foods  (p.  60). 

Condensed  Milk. — Where  the  principal  difficulty  consists  in  incapac- 
ity to  digest  cow's  milk  casein,  condensed  milkf  will  be  found  to  act 
kindly,  since  the  consistency  of  the  coagulum  of  condensed-milk  casein 
formed  in  the  infantile  stomach  greatly  resembles  that  of  human 
milk.  It  has  also  the  advantages  of  being  inexpensive  and  not  as 
readily  subject  to  contamination  as  ordinary  cow's  milk.  However, 
containing  as  it  does  about  51  per  cent  of  sugar,  and  requiring  eight 
to  ten  times  dilution  to  approximate  the  sugar  content  of  human  milk, 

*Malt  soup  extracts  are  now  procurable  in   every  reliable  pharmacy. 
fApproximate   Composition   of   Canned   Condensed   Milk: 

Protein  Sugar  Fat  Salts  Water 

8.00  51.00  7  1.50  32.00 

Fresh  condensed  milk  contains  only  10  per  cent  of  sugar. 


,  PREVENTION    AND    CONTROL   OP   DISEASE  57 

the  simultaneous  reduction  (by  dilution)  of  the  fat  and  proteid  con- 
tents to  about  1  per  cent  and  ll^  per  cent  respectively,  renders  con- 
densed milk  too  poor  in  quality  to  serve  as  an  ideal  infant  food.  In- 
deed, it  is  usually  found  that  infants  over  three  months,  fed  on  di- 
luted condensed  milk,  soon  contract  rachitis.  Nevertheless,  as  a  tem- 
porary food,  especially  during  the  summer  months  or  on  a  long  journey, 
it  is  invaluable.  As  already  suggested,  condensed  milk  should  be  ad- 
ministered in  quantities  appropriate  for  the  infant's  age,  in  dilution 
with  from  eight  to  ten  or  even  twelve  parts  of  plain  or  cereal  water. 
The  deficiency  of  fat  may  be  supplemented  by  the  addition  of  cream. 
'W'hey. — ^Where  the  digestive  capacity  of  casein  is  greatly  at  fault, 
we  may  temporarily  resort  to  whey  feeding.  Whey  is  obtained  by 
adding  to  a  pint  of  fresh  warm  (100°  F.)  milk,  two  teaspoonfuls  of  es- 
sence of  pepsin.  After  it  stiffens,  beat  up  the  curd  with  a  fork  and  strain 
through  a  few  layers  of  gauze,  so  as  to  withhold  the  coagulated  casein. 
The  decanted  liquid  contains  approximately: 

Protein  Sugar  Fat 

Laetalbumin 0.9%  4.5%  0.5% 

Casein 0.3% 

By  adding  a  little  cream  to  overcome  its  deficiency  and  employing  a 
cereal  diluent  instead  of  plain  water,  the  whey  mixture  is  amply  nu- 
tritious to  sustain  an  infant's  vitality  for  several  weeks. 

Buttermilk* — This  is  prepared  by  thoroughly  mixing,  in  a  suitable 
agate  vessel,  one  quart  of  fresh,  rich  milk,  with  a  pint  or  less  of  water, 
a  pinch  of  salt,  and  the  pure  lactic  acid  culture  (any  one  of  the  pure 
mercantile  lactic  bacilli  tablets  answers  the  purpose).  The  vessel  is 
covered  with  a  thin  cloth  and  allowed  to  stand  in  the  room  (70°  to  80° 
F.)  for  from  eighteen  to  twenty-four  hours.  It  is  now  placed  on  ice 
until  needed.  For  infant  feeding  we  add  to  every  quart  of  buttermilk 
a  flat  tablespoonful  of  wheat-flour  and  two  tablespoonfuls  of  cane  sugar 
and  allow  the  mixture  to  toil  over  a  low  fire,  for  two  to  three  minutes, 
with  constant  stirring.  The  food  is  now  poured,  in  quantities  varying 
with  the  age  of  the  patient,  into  sterilized  bottles,  properly  corked, 
and  placed  on  ice  until  used.  The  mixture  is  indicated  especially 
in  cases  requiring  a  high  percentage  of  protein  and  a  low  percentage  of 
fat,  e.  g.,  gastroenteritis  and  fat  indigestion. 

Eiweissmilch  ( Albumin-,  Protein-,  or  Casein-  Milk). — This  food,  orig- 
inally recommended  by  H.  Finkelstein  and  L.  Meyer,  is  gradually  be- 
ing accepted  by  the  profession  as  an  ideal  food  in  the  management  of 
fermentative  dyspepsia  and  nutritional  disturbances  from  intolerance  of 


•Composition:     Water:  90.27;  protein:  4.06;  fat:  0.93;  sugar:  3.73;  salts:  0.67. 


58  DISEASES   OF    CHILDREN 

milk.  It  consists  of  2.50  per  cent  of  fat,  1.5  per  cent  of  sugar,  3  per 
cent  of  protein,  and  0.50  per  cent  of  salts,  and  is  prepared  as  follows: 
One  liter  of  warm  milk  is  treated  with  15  grams  of  essence  of  pepsin, 
and  allowed  to  stand  in  a  water  bath  at  107.6°  F.,  until  a  curd  is  formed. 
This  mass  is  poured  into  a  linen  bag  and  allowed  to  filter  for  about  half 
an  hour,  and  while  gradually  adding  half  a  liter  of  water  the  curd  is 
pressed  through  a  fine  sieve  two  or  three  times  by  means  of  a  wooden 
spoon.  To  this  milk-like  mixture  we  next  add  half  a  liter  of  butter- 
milk. Finkelstein  and  Meyer  were  prompted  to  suggest  the  Eiweiss- 
milch  after  establishing  the  facts  that  nontoxic  fermentative  dyspepsia  is 
due  principally  to  abnormal  fermentation  of  the  carbohydrates  (not  the 
casein!)  of  the  infant  food,  and  that  fat  forms  a  disturbing  element 
only  when  preceded  by  sugar  fermentation.  Albumin  milk  should  be 
given  in  quantities  of  about  li/o  to  2  ounces  every  three  or  four  hours. 
In  very  young  infants  it  may  at  first  be  diluted  with  an  equal  quantity 
of  plain  water  and  later  barley  water.  As  the  patient  improves,  it  is 
advisable  to  increase  the  amount  of  the  Eiweissmilch  and  to  strengthen  it 
also  by  the  addition  of  1  per  cent  of  maltose,  or  malt  dextrin.  After 
full  recovery  from  the  disease,  Eiweissmilch  feeding  is  gradually  dis- 
continued.   Protein  milk  is  now  obtainable  in  powder  form. 

Dry  Milk. — A  number  of  clinicians  have  for  some  time  been  advocating 
the  use  of  dry  milk  in  infant  feeding,  especially  in  cases  of  difficult  diges- 
tion and  on  long  journeys.  The  approximate  composition  of  whole  dry 
milk  is  as  follows :  Fat  25  per  cent,  lactose  40  per  cent,  protein  28  per 
cent,  salts  7  per  cent  and  moisture  5  per  cent.  It  is  usually  adminis- 
tered in  1  to  3  or  1  to  2  dilutions,  with  plain,  boiled,  or  cereal  water,  in 
the  same  manner  as  fluid  milk.  Its  prolonged  use  is  contraindicated, 
even  though  some  pediatrists  claim  that  dry  milk  is  not  productive  of 
scurvy  or  rachitis. 

Mode  of  Manufacture. — The  principal  processes  by  which  dried  milk 
is  made  today  are  briefly  as  follows : 

A.  Milk  is  fed  in  a  thin  stream  over  two  steam-heated  cylinders  or 
drums,  about  one-eighth  of  an  inch  apart  and  revolving  in  opposite  di- 
rections. The  milk  exposed  to  the  heat  of  the  cylinders  dries  as  a  thin 
film  and  comes  off  the  revolving  cylinder  as  a  sheet,  which  is  easily 
crushed  into  a  fine  powder.  The  cylinders,  which  are  some  sixty  inches 
long  and  24  inches  in  diameter,  are  charged  with  steam  under  two  or 
three  atmospheres  of  pressure  causing  the  heating  surfaces  to  have  a 
temperature  of  about  250  to  280°  F.  This  process,  known  as  the  Just 
patent  in  the  United  States  and  as  the  Just-Hatmaker  patent  in  England, 
is  said  to  be  the  invention  of  J.  R.  Hatmaker,  of  London. 


PREVENTION   AND    CONTROL   OF    DISEASE  59 

B.  The  milk  is  first  pasteurized  and  then  condensed  in  the  vacuum 
pan  at  a  low  temperature  (130°  F.)  to  about  one-fourth  of  its  bulk. 
This  condensed  product  is  forced  under  high  pressure  through 
minute  openings  in  a  metal  disk  into  a  hot-air  chamber.  The  atomized 
liquid  surrounded  by  a  current  of  hot  air  instantly  dries  and  falls  to  the 
bottom  of  the  chamber  as  a  snowy  powder,  the  moisture  rising  as  a  cloud 
of  steam.  The  mixture  of  the  liquid  and  air  in  the  evaporating  chamber 
is  stated  to  be  about  180°  F.  This  method  was  originally  developed  in 
France  and  is  called  there  and  in  England  the  Bevenot  de  Neveu  process. 
In  this  country  it  is  known  as  the  Merrill-Gere  process. 

C.  A  third  method  of  making  dried  milk,  by  reducing  it  to  approxi- 
mate dryness  in  a  vacuum  pan  equipped  with  a  mechanical  stirrer,  is 
also  used  in  this  country.  It  has  the  advantage  of  exposing  the  milk  to 
a  low  though  prolonged  temperature. 

Proprietary  Milk  Modifiers  and  Milk  Foods. — ^We  distinguish  two 
kinds  of  proprietary  foods — milk  modifiers  and  so-called  milk  foods. 
Neither  of  them  contain  a  sufficient  amount  of  nutrient  elements  to  sup- 
ply the  needs  of  the  baby  for  life  and  growth  for  any  length  of  time ; 
they  are  useful,  however,  in  digestive  disturbances  and  "milk  idiosyn- 
crasy," and  to  bridge  over  an  acute  siege  of  sickness.  The  mercantile 
milk  modifiers  furnish  soluble  carbohydrates,  free  starch,  or  predigested 
proteids  in  small  quantities,  and  thus  save  the  trouble  of  home  prepara- 
tion of  suitable  diluents.  Their  prolonged  exclusive  use  is  frequently 
followed  by  scurvy  and  rickets. 

Peptonized  Milk. — The  use  of  peptonized  milk  is  nowadays  limited 
chiefly  to  feeding  of  children  of  very  low  vitality,  in  whom  the  powers 
of  digestion  are  in  abeyance,  e.  g.,  high  fever,  coma  (administered  in 
the  form  of  nutrient  enemata,  or  by  gavage),  pylorus  stenosis,  etc. 

Mode  of  Preparation. — Mix  in  a  quart  bottle  one  pint  of  fresh  milk 
with  4  ounces  of  cold  water  containing  5  grains  of  pancreatic  extract 
and  15  grains  of  sodium  bicarbonate,  or  the  contents  of  one  of  Fair- 
child's  peptonizing  tubes.  Place  the  bottle  in  a  pot  of  hot  water  and 
maintain  its  temperature  at  about  115°  F.,  either  for  about  twenty 
minutes  ("partial"  peptonization)  or  two  hours  ("complete"  peptoni- 
zation). Shake  the  bottle  from  time  to  time.  When  the  mixture  is 
ready,  give  it,  either  pure  or  diluted,  in  quantities  suitable  for  the  age 
of  the  child.    Keep  it  on  ice  until  used. 

Weaning  the  Baby  and  Its  Feeding  Thereafter 

Ordinarily  it  is  not  advisable  to  nurse  an  infant  beyond  ten  or 
eleven  months  old.  As  exceptions  to  this  rule,  we  may  mention  the 
very  hot  summer  months,  acute  diseases,  difficult  teething,  etc.,  when 
a  complete  change  in  feeding  is  prone   to  prove  hazardous  to  the 


60  DISEASES    OF    CHILDREN 

child's  health.  It  is  preferable  to  wean  a  baby  gradually,  by  substi- 
tuting bottle-  for  breast-feedings,  and  to  continue  partially  to  nurse 
it,  until  the  infant  has  learned  to  submit  to  the  inevitable,  and  thrives 
well  on  the  new  food. 

Feeding  of  I^ifants  Over  Seven  Months  Old. — When  the  normal  infant 
reaches  the  age  of  seven  months  or  thereabouts,  nature  announces  the 
urgency  of  a  change  in  the  dietary — from  liquid  to  solid — by  has- 
tening the  eruption  of  the  lower  and  upper  incisors.  At  this  age, 
also,  salivary  digestion  is  fully  established,  so  that  an  allowance, 
once  or  twice  a  day,  of  a  crust  of  stale  or  toasted  bread,  or  zwie- 
back, certainly  can  do  no  harm.  As  at  this  period  of  life  the  ten- 
dency to  rickets  is  very  pronounced,  the  dietary  should  be  grad- 
ually improved  upon  by  the  addition  of  small  quantities  of  cereals, 
a  teaspoonful  or  more  of  fresh,  soft-boiled  eg^,  strained  chicken, 
mutton,  or  beef  soup,  with  fresh  vegetables  (e.  g.,  carrots,  potatoes,  etc.), 
orange  or  pineapple  juice,  baked  potato  with  some  sweet  cream  or  but- 
ter; and  later  (at  about  a  year,)  bread  and  butter,  milk  custards,  cocoa, 
and  occasionally  finely  scraped  beef  or  chicken. 

Of  course  the  transition  from  an  exclusive  milk  diet  to  a  more  or 
less  mixed  diet  must  be  very  slow  and  gradual.  The  effect  of  the 
change  should  be  watched  frorii  day  to  day  and  week  to  week,  al- 
ways bearing  in  mind  that  milk  is  the  ideal  food  for  the  infant  and 
indispensable  to  the  child  up  to  the  period  of  second  dentition. 

This  fact  should  be  strongly  impressed  upon  those  in  charge  of  the 
child,  as  only  too  often,  with  the  allowance  of  a  semisolid  diet,  milk 
is  crowded  out  entirely  by  an  oversupply  of  thin  soups,  indigestible, 
proprietary  ''breakfast  foods,"  and  all  sorts  of  sweets  and  fruit  of 
poor  quality,  which  sooner  or  later  upset  the  child's  digestive  powers 
and  arrest  its  growth  and  development — doing  just  the  opposite  of 
what  the  change  of  diet  was  intended  for. 

With  the  change  in  the  diet  it  is  also  frequently  observed  that  the 
infants  refuse  to  drink  milk.  Inquiry  into  the  cause  usually  reveals 
the  fact  that  upon  the  advice  of  some  artistically  inclined  neighbor — 
who  thinks  that  the  bottle  effaces  the  child's  "beauty  lines" — and 
more  generally  upon  the  recommendation  of  the  family  physician,  the 
child  is  forced  to  part  with  its  bottle  and  nipple — its  dear  and  faith- 
ful companions  for  the  many  months  past.  Why  milk  bottles  are  to 
be  looked  upon  as  an  abomination  for  children  over  a  year  or  so  and 
as  a  salvation  for  those  vnder  this  age,  is  to  me  a  mystery.  The  mere 
facts  that  if  given  in  a  bottle,  large  quantities  of  milk  are  enjoyed  by 
children  up  to  four  or  five  years  of  age ;  that  if  taken  through  a  nipple, 
milk  enters  the  stomach  slowly,  and,  hence,  is  more  easily  digested,  and 
finally,  that  during  sickness  milk  (as  well  as  water)  is  best  administered 


PREVENTION    AND    CONTROL    OF   DISEASE  61 

through  a  bottle,  are  ample  justifications  for  the  encouragement  rather 
than  the  prohibition  of  the  use  of  the  bottle — provided,  of  course,  that 
the  bottles,  as  well  as  the  nipples,  are  kept  scrupulously  clean ;  are 
sterilized,  if  you  please. 

The  additional  articles  of  food  should  be  given  at  definite  intervals, 
preferably  together  with  the  milk  feeding.  Thus,  for  example,  with  the 
ten  o'clock  bottle  the  child  should  receive  the  soft-boiled  or  poached 
egg  and  crackers;  at  two  o'clock  the  meat  broth  and  potato;  at  six 
o'clock,  some  cereal  and  bread  and  butter.  Orange  or  pineapple  juice 
may  also  be  given  between  meals.  The  child  should  be  taught  to  ap- 
preciate that  to  get  other  foodstuffs  it  must  drink  its  allowance  of  milk. 

Diet  for  Child 
From  18th  to  24th  Month 
Breakfast 

1.  Juice  of  1  sweet  orange 

or 
Pulp  of  6  stewed  prunes 

or 
Pineapple  juice   (fresli  or  bottled)   1  ounce. 

2.  Dessert:   apple  sauce,  prune  pulp,  with  stale  lady-fingers  or  graham  wafers. 

top  milk    (top   16   ounces)    sweetened  or  salted.     A  glass  of   milk,   bread   and 

butter. 

Note:  If  constipated  give   the   fruits  half-hour  before   breakfast  with  water; 

if  not,  they  may  be  given  during  the  forenoon. 

Eaw  fruit  juice  must  be  given  either  half -hour  before  or  half -hour  after  milk. 

Forenoon 
A  glass  of  milk  with  two  toasted  biscuits  or  zwieback  or  graham  crackers. 

Dinner 

1.  Broth  or  soup  made  of  beef,  mutton,  or  chicken,  and  thickened  with  peas,  farina, 

sago  or  rice 
or 
Beef  juice  with  stale  bread  crumbs;  or  clear  vegetable  soup  with  yolk  of  egg 
or 

Egg  soft  boiled,  with  bread  crumbs,  or  the  egg  poached,  with  a  glass  of  milk. 

2.  Dessert :  apple  sauce,  prune  pulp,  with  stale  lady-fingers  or  graham  wafers 

or 
Plain  puddings:  rice,  bread,  tapioca,  blanc-mange,  junket  or  baked  custard,  bread 
and  butter. 

3   p.  TO. 
A  cup  of  milk  with  biscuits. 

Supper 
An  egg,  glass  of  milk,  zwieback  and  custard,  or  stewed  fruit. 
Total  milk  in  24  hours,  1  quart. 

Diet  for  Child 

From  Two  to  Three  Years 

BrealcfOrSt 
1.  Juice  of  1  sweet  orange 
or 
Fulp  of  6  stewed  prunes 

or 
1  ounce  pineapple  juice  Cf  resh  or  bottled) 

or  ^ 

Apple  sauce  (warm). 


62 


DISEASES   OF    CHILDREN 


2.  A  cereal  such  as  oatmeal,  farina,  cream  of  wheat,  hominy  or  rice,  slightly  sweet- 

ened, or  salted,  as  preferred,  with  the  addition  of  top  milk. 
or 
A  soft  boiled  or  poached  egg  with  stale  bread  or  toast, 

3.  A  glass  of  milk. 

Note:     If  constipated  give  the  fruits  5^  hour  before  breakfast  with  water;  if  not, 
they  may  be  given  during  the  forenoon. 
Milk  and  raw  fruit  juice  must  not  be  given  at  same  meal. 

Binner 

1.  Broth  or  soup  made  of  chicken,  mutton  or  beef,  thickened  with  arrowroot,  split 

peas,  rice,  or  with  addition  of  the  yolk  of  an  egg  or  toast  squares. 

2.  Scraped  beef  or  white  meat  of  chicken  or  broiled  fish  (small  amount")  bread  and 

butter 
or 
Mashed  or  baked  potatoes  with  fresh  peas  or  spinach  or  carrots. 

3.  Dessert:     apple  sauce,  baked  apple,  rice  pudding,  junket  or  custard. 

3  p.  TO. 
A  cup  of  milk  with  biscuits. 

Supper 

1.  A  cereal  or  egg  with  stale  bread  or  toast  and  butter.     Cup  of  cocoa. 

or 
Bread  and  butter  and  milk,  or  bread  and  butter  and  cocoa,  or  bread  and  custard. 

2.  Stewed  fruit. 

Feeding  of  Children  from  Four  to  Six  Years  Old. — The  dietary  of 
children  over  four  years  old  is  practically  identical  with  that  just  men- 
tioned, except  that  the  quantity  of  the  food  should  be  more  liberal,  the 
fruit  may  be  given  raw,  and  that  the  between-meals  milk  allowance 
should  be  dispensed  with.  Occasionally  the  child  may  receive  home- 
made cake,  a  little  ice  cream  and  other  condiments  of  good  quality.  All 
these  foodstuffs,  however,  should  be  given  with  regular  meals. 


Average  Composition  of  Common  American  Food  Products* 


Food   materials    (as 
purchased). 


Sirloin  steak 

Round  steak 

Veal,  leg  cutlets .  . . 

Veal,  breast 

Mutton,  leg,  hind . . 
Mutton,  loin  chops. 

Lamb,   breast 

Pork,  loin  chops.  . . 

Ham,  smoked 

Bacon,  smoked 

Soup,    beef 

Soup,  tomato 


P3 


p.  c. 

12.8 

7.2 

3.4 

21.3 

18.4 

16.0 

19.1 

19.7 

13.6 

7.7 


p.  c. 

54.0 
60.7 
68.3 
52.0 
51.2 
42.0 
45.5 
41.8 
34.8 
17.4 
92.9 
90.0 


p.  c. 

16.5 

19.0 

20.1 

15.4 

15.1 

13.5 

15.4 

13.4 

14.2 

9.1 

4.4 

1.8 


p.  c. 

16.1 
12.8 

7.5 
11.0 
14.7 
28.3 
19.1 
24.2 
33.4 
62.2 
.4 

1.1 


CS    j3 

O 


p.  c. 


1.1 

5.6 


p.  c. 

.9 

1.0 

1.0 

.8 

,8 

.7 

.8 

,8 

4,2 

4.1 

1.2 

1.5 


C3      c3 


Ph    p. 


Calo- 
ries. 

975 

890 

695 

745 

890 

1,415 

1,075 

1,245 

1,635 

2,715 

120 

185 


'After  Nelson's  Perpetual  Loose  Leaf  Encyclopaedia. 


PREVENTION   AND    CONTROL   OF    DISEASE 


63 


Average  Compositiox  of  Common  American  Food  Products — Cont'd 


Food  materials   (as 
purchased). 

o 

CO 

3 

o 

o  2 

TO       '5 

4S 
< 

11 

1  s 

Chicken,   broilers 

Fowls   

p.  c. 

41.6 
2.5.9 
2^.9 
44.7 

J),  c. 

43.7 
47.1 
58.5 
40.4 
63.5 
88.3 
30.7 
65.5 
11.0 
87.0 
91.0 
74.0 
34.2 
11.4 
12.0 
12.5 

7.7 
12.3 
11.4 
35.3 
35.7 
19.9 

5.9 

p.c. 

12.8 

13.7 

11.1 

10.2 

21.8 

6.0 

5.9 

13.1 

1.0 

3.3 

3.0 

2.5 

2*5.9 

13.8 

11.4 

9.2 

16.7 

8.0 

.4 

9.2 

8.9 

6.3 

9.8 

p.  c. 

1.4 

12.3 

.2 

4.2 

12.1 

1.3 

,7 

9.3 

85.0 

4.0 

.5 

18.6 

33.7 

1.9 

1.0 

1.9 

7.3 

.3 

.1 

1.3 

1.8 

9.0 

9.1 

p.  c. 

3.3 
.2 

5.0 

4.8 

4.5 

2.4 

71.9 

75.1 

75.4 

66.2 

79.0 

88.0 

53.1 

52'.1 

63.3 

73.1 

70.0 

96.0 

100.0 

59.6 

4.8 

2.6 

8.9 

16.9 

14.7 

21.9 

3.9 

10.8 

66.1 

14.3 

14.4 

4.6 

8.5 

7.0 

'2.7 

68.5 

56.4 

18.5 

6.8 

30.3 

37.7 

1.4 

p.  C. 

.7 

.7 

.8 

.7 

2.6 

1.1 

.8 

0.9 

3.0 

.7 

.7 

.5 

3.8 

1.0 

.5 

1.0 

2.1 

.4 

,1 

1.1 

1.5 

1.5 

2.1 

3.5 

.9 

.8 

.5 

1.0 

.8 

.9 

.5 

.3 

2.0 

.6 

.4 

.3 

A 

.6 

.1 

3.1 

1.7 

1.5 

.6 

2.2 

7.2 

.2 

Calo- 
ries. 
305 
765 

Cod,  dressed 

220 

Mackerel,  whole 

370 

915 

225 

Lobsters  

61.7 
all.2 

145 

Hens '  eggs 

635 

Butter 

3,410 

310 

Buttermilk 

160 

865 

1,885 

Entire-wheat  flour 

1  650 

1  635 

1,635 
1,800 
1,620 

Oat  breakfast   food 

Rice 

Tapioca 

1,650 
i,200 

Bread,    Graham   .  . 

1,195 

Cake 

1,630 

Soda  crackers  

1,875 

Molasses 

1,225 

1,680 

Sugar,  granulated 

1,750 

Beans,  dried 

12.6 

77.7 

75.6 

78.9 

74.6 

62.6 

55.2 

94.3 

63.3 

28.1 

48.9 

58.0 

44.8 

63.4 

85.9 

37.5 

13.1 

4.5 

6.9 

1.0 

5.9 

4.6 

98.2 

22.5 

1.4 

.9 

1.4 

7.0 

1.8 

1.4 

.9 

.3 

1.6 

.8 

1.0 

.3 

.6 

.9 

.2 

2.3 

8.1 

19.5 

6.9 

12.9 

21.6 

.2 

1.8 
.2 
.1 
.3 
.5 
.1 
,6 
.4 
.3 

2.2 
.4 

1.2 

.1 
.6 
.1 

3.0 
5.3 
29.1 
26.6 
48.7 
28.9 

1,520 

Cabbage  

15.0 
20.0 
10.0 

115 

Celery 

65 

Onions    

190 

Peas,  shelled 

440 

Potatoes,   white 

20.0 
20.0 

295 

Potatoes,   sweet 

Tomatoes 

440 
100 

Apples,   fresh 

Apples,  dried 

25.0 

190 
1,185 

Bananas  

35.0 
25.0 
50.0 
27.0 
5.0 
59.4 
10.0 
24.0 
24.5 
58.1 

260 

Grapes   

295 

Muskmelons    

80 

Oranges   

Strawberries   

150 
150 

Watermelons 

50 

Raisins 

1,265 
1,385 

Chestnuts 

Peanuts   

1,775 

Walnuts,  English 

Chocolate 

1,250 
2.625 

Cocoa,  powdered    

Cereal   coffee,   infusion 
(1  part  boiled  in  20 
parts   water) 

2,160 

30 

64  DISEASES  OF   CHILDREN 

II.  HYGIENE  AND  SANITATION 

Next  to  suitable  nutrition,  hygiene  and  sanitation  play  the  most  im- 
portant role  in  the  preservation  of  good  health.  It  is  within  the 
province  of  the  physician's  duties  to  formulate,  to  those  intrusted 
with  the  care  of  the  child,  rules  and  regulations  as  to  its  cleanliness 
and  comfort,  mode  of  clothing,  time  for  sleeping,  airing,  bathing, 
rest  and  exercise,  both  during  health  and  disease.  Without  the  advice 
and  supervision  of  the  physician,  the  nurse  or  mother  is  only  too  apt 
either  to  overdo  or  underdo,  i.  e.,  in  both  events  do  irreparable  damage 
to  the  health  and  welfare  of  the  child.  Unfortunately  blind  credulity, 
stupid  mysticism  and  absurd  fatalism  still  reign  supreme,  the  great 
strides  in  science  and  adventure  notwithstanding. 

General  Care  of  the  Newborn  and  Older  Children 

The  Newiorn. — Immediately  after  birth  the  infant  instinctively,  by 
its  shrill  cry,  announces  its  demand  for  protection  against  the  sharp 
change  of  atmosphere  and  surroundings.  Therefore,  after  dressing  its 
navel  (p.  221),  washing  its  eyes  and  mouth  with  a  saturated  boric  acid 
solution,  and  instillation  into  each  eye  of  one  drop  of  a  2  per  cent  solu- 
tion of  nitrate  of  silver,  the  baby  should  be  wrapped  in  a  warm  woolen 
blanket  and  placed  in  a  warm,  darkened,  but  airy,  quiet  room,  and  left  to 
rest  for  a  few  hours.  It  should  then  be  sponged  off  with  warm  soap 
water,  dressed,  given  a  little  clean  water,  and,  the  condition  of  the  mother 
permitting,  put  to  the  breast  (p.  44).  Whenever  possible,  the  child's  crib 
should  be  kept  in  a  room  apart  from  that  of  the  mother,  so  that 
the  latter  is  not  disturbed  by  the  possible  uneasiness  experienced  by 
the  baby.  As  lactation  is  usually  not  fully  established  before  the 
third  or  fourth  day  after  labor,  the  infant  should,  in  the  meantime, 
several  times  daily  receive  a  few  teaspoonfuls  of  plain  or  slightly 
sweetened  warm  water  or  of  a  mild  carminative,  such  as  fennel-seed 
tea,  to  satisfy  its  thirst  and  hunger. 

Sleep. — The  normal  newly  born  baby  sleeps  practically  all  the  time 
except  the  brief  periods  occupied  with  nursing,  diapering,  and  dress- 
ing. If  the  baby  is  well  developed  and  strong,  it  should  be  left  to 
sleep  until  it  wakes  up  of  its  own  accord  from  hunger;  if  delicate,  it 
should  be  aroused  every  two  or  three  hours  during  the  day,  and  once 
at  night,  made  to  cry  a  little  to  help  to  expand  its  lungs  and  put  to  the 
breast  for  from  ten  to  twenty  minutes.  At  six  weeks  the  infant  needs 
twenty  hours  of  sleep ;  at  three  months,  eighteen ;  at  one  year,  sixteen, 
and  from  two  to  four  years,  fourteen  hours  of  sleep.  All  children 
should  get  accustomed  to  sleep  uninterruptedly  (except  for  one  nurs- 


PREVENTION    AND    CONTROL   OF   DISEASE  65 

ing  in  the  middle  of  the  night  in  early  infancy),  from  seven  in  the 
evening  until  seven  o'clock  in  the  morning,  and  one  hour  each  some 
time  between  seven  and  twelve  o'clock  in  the  forenoon  and  two  and 
seven  in  the  afternoon. 

Sleeplessness  in  the  infant  is  ordinarily  due  to  intestinal  colic  or 
other  pain,  discomfort  from  soiled  diapers  or  faulty  dressing  (over- 
heating by  superabundance  of  clothes,  etc.),  noise  in  the  room,  lack 
of  ventilation,  bad  habits,  such  as  rocking,  or  keeping  an  empty  nipple 
in  the  mouth,  etc.  Repeated  waking  is  frequently  due  to  over-  or 
under-feeding. 

Bathing. — In  view  of  possible  local  or  systemic  infection  (p.  219) 
through  the  umbilical  rest,  and  the  advisability  of  keeping  the  latter 
perfectly  dry,  the  full  tub  bath  should  be  Avithheld  until  the  navel 
has  completely  healed.  The  same  applies  for  circumcision  wounds. 
In  the  meantime  the  infant  should  receive  at  least  one  sponge  bath  a 
day,  to  be  given  as  gently  as  possible,  since  the  infantile  skin  is  very 
delicate,  very  apt  to  be  abraded  on  rough  handling,  and  readily  be- 
comes subject  to  divers  skin  affections. 

In  the  absence  of  the  aforementioned  or  other  contraindications, 
every  child,  in  addition  to  local  cleansing  as  frequently  as  necessity 
arises,  should  receive  a  tub  bath  once  a  day,  preferably  at  bedtime. 
The  water  used  should  be  free  from  visible  impurities,  and  obtained 
from  sources  inaccessible  to  pollution.  The  temperature  of  the 
water  should  range  between  95°  F.  and  98°  F.,  the  latter  for  infants 
under  six  months,  and  cooler  water  for  older  ones.  Fat  babies  toler- 
ate much  lower  temperatures,  but  I  see  no  special  benefit  to  be  de- 
rived from  the  use  of  bath  water  under  95°  F.  unless  it  be  in  the  open 
sea  or  ocean  (which  is  permissible  in  children  over  three  years  of  age), 
where  the  saline  ingredients  and  forceful  current  exert  a  stimulat- 
ing, refreshing  effect  upon  the  system  and  thus  counteract  the 
depression  produced  by  the  sudden  lowering  of  the  body  tempera- 
ture. If  cool  bathing  is  desirable,  it  is  better  to  place  the  child 
in  warm  water  and  either  gradually  cool  off  the  water  while  the  child 
is  in  the  tub  or  use  a  cold  shower.  The  bath  should  be  followed  -by 
thorough  drying  of  the  body  and  gentle  friction.  Care  should  be  ex- 
ercised in  the  selection  of  pure,  nonirritating  bathing  soap,  lest  its 
irritating  ingredients  may  prove  a  source  of  annoying  skin  eruptions. 
For  the  same  reason  and,  furthermore,  owing  to  the  fact  that  they 
are  apt  to  harbor  dirt  and  disease,  the  use  of  sponges  is  to  be  depre- 
cated. 

Clothing. — Infants  should  be  clothed  warmly  and  simply,  free  from 
fancy  frocks  and  frills,  strings  and  bows,  that  embarrass  free  motion, 


66  DISEASES    OF    CHILDREN 

breathing,  sleeping  and  eating.  The  underwear  should  be  made  of  silk 
or  thin  flannel.  The  abdomen  should  be  protected  against  being  chilled 
by  a  flannel  band.  The  consistency  of  the  outer  clothing  should  vary 
with  the  changes  of  the  weather  and  season  of  the  year.  The  feet 
of  infants  should  at  all  times  be  kept  warm,  if  necessary,  by  means 
of  a  hot-water  bag.  The  night  clothes  should  be  loose  and  warm, 
and  consist,  in  addition  to  a  small  silk  or  flannel  shirt,  Canton  flannel 
or  stockinet  diaper  and  the  belly-band,  of  a  nightshirt  in  the  form 
of  a  "bag"  that  buttons  around  the  neck  and  can  be  closed  at  the 
feet  by  means  of  drawstrings.  In  this  manner  the  unnecessary  pil- 
ing up  of  blankets,  to  keep  the  baby  from  uncovering,  can  be  advanta- 
geously dispensed  with. 

Older  children  should  gradually  get  accustomed  to  light  clothes — 
linen  or  silk  undergarment,  linen  or  woolen  suit  or  dress,  and  for  the 
winter  a  warm  top  coat  and  cap — but  no  collars  or  neck  mufflers.  A 
woolen  union  suit  with  feet  for  the  night.  Special  attention  should 
be  paid  to  the  selection  of  shoes.  They  should  comfortably  fit  the 
feet  and  allow  spreading  of  the  toes.  The  stockings  should  be  fas- 
tened to  the  drawers,  as  garters  are  apt  to  interfere  with  the  blood 
circulation  of  the  lower  extremities.  The  corset  should  be  prohibited 
in  girls  under  fourteen. 

Airing. — Fresh,  pure  air  is  the  panacea  for  good  health,  the  cure  of 
all  bodily  ills.  Thus  far  it  is  nonassessable,  nontaxable,  and  hence 
should  be  inhaled  ad  liditum — while  this  freedom  lasts.  Weather  per- 
mitting, it  should  be  inhaled  out  of  doors,  otherwise  indoors — in  prop- 
erly ventilated  rooms.  The  newborn  should  be  taken  outdoors  in  the 
summer  when  it  is  two  weeks  old,  in  the  spring  and  fall  at  one  month 
and  in  the  winter  at  two  months  of  age  or  later.  It  should  be  suitably 
dressed  and  protected  from  undue  exposure  to  the  sun  and  wind  and 
severe  cold.  It  is  foolhardy  to  expose  an  infant  to  marked  atmos- 
pheric changes  without  proper  shelter,  merely  for  the  purpose  of 
"hardening"  it.  Its  first  airing  should  last  from  fifteen  to  thirty 
minutes,  and  as  it  grows  older  the  airing  time  should  be  lengthened, 
so  that,  weather  permitting,  the  child  may  live  outdoors  the  greater 
part  of  the  day  from  sunrise  until  sunset.  Slight  rain  or  snow  forms 
no  hindrance  to  taking  the  baby  outdoors,  although  in  such  weather 
delicate  babies  do  better  if  aired  indoors,  in  front  of  open  windows 
and  dressed  as  for  outdoors. 

Exercise. — A  healthy  infant,  if  not  immobilized  by  burdensome 
clothes,  begins  to  take  physical  exercise  soon  after  birth.  It  kicks, 
moves  its  arms  and  head  and  exercises  its  thoracic  muscles  while  cry- 
ing lustily,  especially  when  feeding  time  approaches.     It  should  be 


PREVENTION    AND    CONTROL   OF    DISEASE  67 

picked  up  in  the  arms  at  every  nursing  to  insure  change  of  position. 
At  about  four  months  of  age  the  baby  is  able  to  hold  its  head  erect; 
it  may  then  be  gradually  trained  to  sit  upright  upon  the  arm  of  the 
nurse,  its  back  and  head  well  supported.  As  it  reaches  the  age  of 
seven  or  eight  months,  the  infant  may  be  seated  alone  in  a  baby-chair 
supported  with  pillows  at  the  back  and  sides.  When  it  shows  an 
effort  to  creep,  it  may  be  placed  upon  the  floor,  which  should  be  well 
covered  by  thick  carpet  or  a  blanket,  preferably  within  a  small  porta- 
ble "creeping  pen,"  and  allowed  to  roam  about  for  half  an  hour 
at  a  time  once  or  twice  a  day.  Less  freedom  should  be  granted  an 
infant  in  its  first  attempts  to  stand  or  walk.  These  practices  should 
not  be  encouraged  in  babies  under  one  year  of  age,  nor  in  older  chil- 
dren who  show  a  tendency  to  bony  curvatures  and  rickets.  In  the 
beginning  they  should  not  be  allowed  to  stand  or  walk,  especially 
if  unsupported,  for  more  than  a  few  minutes  at  a  time.  But,  as  they 
grow  older  and  stronger,  they  are  gradually  permitted  to  enjoy  shorter 
or  longer  outdoor  walks  and  to  romp  merrily,  giving  vent  to  that 
characteristic  boundless  joyousness  of  early  childhood  which  is  bless- 
edly ignorant  of  the  pangs  and  pains  of  later  life. 

Older  children,  like  infants,  should  spend  the  greater  portion  of 
the  day  outdoors  in  parks  and  playgrounds  and  engage  in  amusing 
games  and  light  calisthenics  which  will  keep  them  from  harm  and 
mischief.  It  is  opportune  on  this  occasion  to  emphasize  the  danger 
of  overindulgence  in  the  practice  of  gymnastics,  especially  in  children 
of  school  age — a  period  of  life  which  is  coincident  with  prevalence  of 
communicable  diseases  and  their  grave  sequelse,  particularly  cardiac 
involvement. 

It  is  the  duty  of  the  physician  to  impress  upon  those  under  his 
care  that  while  moderate  exercise — especially  walking,  skating  and 
horse-back  riding;  the  daily  use,  for  about  fifteen  minutes  at  a  time, 
of  light  wooden  dumb-bells,  light  clubs  or  wands ;  the  practice  of  breath- 
ing (p.  4-39),  of  swinging  of  the  body  from  a  swinging  bar  or  rings 
and  straps, — will  do  much  for  the  development  of  delicate  and  narrow 
chests  and  to  prevent  and  straighten  curvatures  of  the  spine,  stooping 
of  the  shoulders,  and  the  like  (and  should  be  encouraged),  violent 
sports,  like  racing,  rough  baseball-  and  football-playing,  leaping,  pro- 
longed swimming  and  similar  severe  exercises  indulged  in  to  excess, 
will  sooner  or  later  lead  to  cardiac  hypertrophy  with  its  consequences. 

Nursery. — As  infants  and  older  children  spend  about  two-thirds  or 
more  of  their  time  of  life  in  the  nursery,  provisions  must  be  made  that 
the  room  is  spacious  and  airy,  dry  and  sunny,  that  its  air  is  fresh  and 
pure,  free  from  obnoxious  odors,  gases,   dust  and  smoke.     To  thrive 


68  DISEASES  OF   CHILDREN 

well  an  infant  requires  about  1000  cubic  feet  of  air  space.  The  room 
should  not  be  crowded  with  dust  gatherers,  i.  e.,  overabundance  of  fur- 
niture, toys,  heavy  hangings,  carpets,  rugs,  pictures,  etc.  The  tem- 
perature of  the  room  should  be  about  70°  F.  during  the  day  and  about 
65°  F.  during  the  night.  Whenever  possible,  it  should  be  heated  from 
an  open  fireplace  or  hot-air  furnace.  Steam  heat  or  gas  often  vitiates 
the  air.  To  insure  proper  ventilation,  it  is  advisable  to  keep  the  win- 
dows more  or  less  open  from  top  and  bottom  most  of  the  time  unless  the 
outdoor  temperature  is  below  35°  F.  The  windows  and  doors  should 
be  widely  opened  while  the  child  is  outdoors,  otherwise  ventilation  should 
be  accomplished  with  the  doors  closed  to  avoid  draughts.  For  the  latter 
purpose  one  of  the  many  ventilating  devices  on  the  market  will  prove 
very  serviceable. 

Financial  circumstances  permitting,  every  child  should  have  a  sep- 
arate room,  if  possible,  situated  one  floor  above  the  ground.  Of  course, 
this  is  rarely  attainable  in  the  dingy  apartments  of  overcrowded  cities. 
Physicians  should  insist,  however,  on  every  child  having  a  separate  bed 
in  order  to  minimize  the  danger  of  transmitting  communicable  diseases 
from  the  sick  to  the  healthy  child. 

The  Sick-Boom. — The  hygienic  suggestions  just  made  in  reference 
to  the  nursery  apply  with  greater  force  to  the  sick-room.  If  possible, 
the  latter  should  be  situated  on  a  different  floor  from  the  living  apart- 
ments. From  a  sanitary  as  well  as  economic  point  of  view  it  is  essen- 
tial to  have  the  sick-room  cleared  of  curtains,  tapestries,  superfluous 
furniture,  carpets,  etc.,  so  as  to  facilitate  keeping  the  room  perfectly 
clean,  and  to  prevent  pathogenic  germs  becoming  firmly  imbedded  in 
those  articles.  The  floor  and  furniture  of  the  sick-room  should  be  wiped 
off  with  a  damp  cloth  instead  of  dusted  or  swept. 

An  anteroom  is  a  useful  addition  to  a  sick-room  especially  when  the 
patient  is  suffering  from  a  communicable  affection,  as  it  enables  the 
nurse  to  disinfect  the  dishes,  soiled  bedclothes,  linen,  etc.,  and  to  pre- 
pare some  of  the  patient's  food. 

When  the  isolation-period  of  the  patient  is  over,  the  sickroom,  ante- 
room and  their  contents  must  undergo  very  thorough  cleaning  and  dis- 
infection. 

Quarantine  and  Disinfection. — In  order  to  prevent  spreading  of  com- 
municable diseases  from  one  individual  to  another,  we  have  to  resort 
principally  to  the  following  prophylactic  measures: 

1.  Isolation  of  the  patient. 

2.  Disinfection  of  the  patient's  excretions,  fomites,  etc.,  coming  in 
contact  with  the  pathogenic  microorganisms. 


PREVENTION   AND    CONTROL    OF   DISEASE  69 

3.  Exclusion  of  visitors  and  domestic  animals,  such  as  cats  and  dogs, 
and  destruction  of  other  germ  carriers,  e.  g.,  mosquitoes,  flies  and  fleas. 

1.  Isolation  of  the  Patient.^This  is  the  most  essential  and  efficient 
mode  of  prevention  of  transmission  of  disease.  The  isolation  to  be 
effective  must  begin  early  and  be  complete.  In  hospitals  and  asylums 
every  child  should  be  isolated  in  an  observation  ward  for  at  least  three 
days  before  being  permitted  to  mingle  with  the  other  inmates;  in  pri- 
vate families  isolation  should  be  enforced  with  the  earliest  appearance 
of  tangible  symptoms  of  the  specific  affection.  As  those  coming  in 
close  contact  with  the  patient  are  apt  to  carry  the  disease  from  the 
sick  to  the  well,  it  is  imperative  to  isolate  the  nurse  together  with  the 
patient  and  to  forbid  any  member  of  the  family  to  stay  around  the 
sick-room  or  make  herself  generally  useful,  unless  on  entering  the 
sick-room  she  dons  a  clean  gown  and  cap,  and  before  leaving  it  washes 
her  hands  and  forearms  with  soap  and  water  and  removes  the  gown 
and  cap.     These  latter  rules  should  apply  also  to  the  physician. 

In  a  private  dwelling,  and  especially  in  houses  where  a  room  is  re- 
served for  the  sick,  perfect  isolation  can  readily  be  insured.  In 
crowded  tenement  rooms,  however,  with  people  in  poor  circumstances, 
all  attempts  at  isolation  almost  invariably  fail,  and  where  the  spread- 
ing of  a  grave,  epidemic  affection  is  concerned  {e.g.,  smallpox,  cerebro- 
spinal meningitis),  should  not  at  all  be  attempted.  In  such  cases 
it  is  best  to  remove  the  patient  to  a  hospital  for  contagious  diseases. 

The  period  of  isolation  varies,  of  course,  with  different  diseases  and 
the  degree  of  severity.  The  following  suggestions  will  meet  the  ordi- 
nary requirements  as  to  the  period  of  isolation  and  the  principal  mode 
of  prophylaxis: 

In  typhoid  fever,  while  the  disease  lasts.  (Disinfection  of  excreta; 
protection  against  flies,  fleas,  lice,  etc.) 

In  typhus  fever,  while  the  disease  lasts.     (Same  as  in  typhoid.) 
In  miliary  tuberculosis,  while  the  disease  lasts.     (Disinfection  of  ex- 
creta.) 

In  epidemic  cerebrospinal  meningitis  and  poliomyelitis,  while  the 
disease  lasts.  (Disinfection  of  discharges.) 
In  yellow  fever,  while  the  disease  lasts.  (Destruction  of  mosquitoes.) 
In  relapsing  fever,  while  the  disease  lasts.  (Destruction  of  insects.) 
In  influenza,  pneumonia  and  pulmonary  tuberculosis,  while  the  dis- 
eases last.    (Disinfection  of  discharges.) 

In  bubonic  plague,  about  one  week  after  termination  of  the  disease. 
(Destruction  of  vermin,  especially  rats;  disinfection  of  excreta.) 

In  cholera  Asiatica  and  epidemic  dysentery,  one  week  after  termina- 
tion of  the  disease.  (Disinfection  of  excreta;  avoidance  of  pollution 
of  water,  milk,  etc.) 

In  smallpox,  six  weeks.     (Vaccination;  disinfection  of  discharges.) 
In  chickenpox,  one  week.     (Disinfection  of  discharges  and  skin.) 


70  DISEASES   OF    CHILDREN 

In  measles,  two  weeks.     (Disinfection  of  discharges  and  skin.) 

In  German  measles,  two  weeks.  (Disinfection  of  discharges  and 
skin.) 

In  diphtheria,  as  long  as  diphtheria  bacilli  abound  in  the  throat. 
(Disinfection  of  discharges.) 

In  scarlet  fever,  while  the  desquamation  lasts.  (Disinfection  of  dis- 
charges and  skin.) 

In  whooping-cough,  while  whoop  or  vomiting  lasts.  (Disinfection 
of  expectoration.) 

In  mumps,  tAvo  weeks.     (Disinfection  of  sputum.) 

In  erysipelas,  two  weeks.  (Disinfection  of  the  skin;  antiseptic 
dressing.) 

In  gonorrheal  ophthalmia  or  urethritis,  while  gonococci  are  found  in 
the  discharges. 

Before  leaving  the  isolation  room,  the  patient  should  receive  a 
cleansing,  hot  soap-water  bath  (including  thorough  scrubbing  of  the 
scalp,  ears,  finger-  and  toe-nails),  and  dressed  anew  with  freshly  dis- 
infected clothing. 

2.  Disinfection  of  Excreta,  or  Fomites,  etc.^In  order  to  be  on  the 
safe  side,  the  nurse  should  be  instructed  to  disinfect  the  stools,  urine, 
vomitus,  sputum,  and  nasal,  aural,  conjunctival  and  vaginal  discharges 
of  the  patient,  regardless  of  whether  or  not  they  carry  contagious  matter. 

For  Excreta. — Chloride  of  lime  in  powder  or  in  solution.  Four  ounces 
of  lime  to  one  gallon  of  soft  water.  A  sufficient  quantity  of  this  solu- 
tion should  be  thoroughly  mixed  with  the  feces,  urine,  sputum,  etc., 
and  allowed  to  stand  for  about  three  hours  before  emptying. 

Sputum  is  best  collected  in  paper  cups,  or  small  cloths  and  immediately 
destroyed  by  fire. 

Bichloride  of  mercury  in  solution  1 :500 — a  7i/2  grain  tablet  in  a  pint 
of  water.  Copper  sulphate  in  solution  (5  per  cent).  Zinc  sulphate  in 
solution  (10  per  cent).    Cresol  or  creolin  in  solution  (5  per  cent). 

For  Clothing,  Bedding,  Linen,  etc. — Destruction  by  fire — the  safest 
measure.  Exposure  to  dry  heat  at  a  temperature  of  about  300°  F.,  or 
moist  heat  at  212°  F.,  for  two  hours.  Boiling  for  at  least  half  an  hour. 
Immersion  in  a  bichloride  solution  (1 :2000)  for  about  three  hours.  Fumi- 
gation by  formaldehyde.     (See  below.) 

For  the  Hands,  General  Body,  Dishes,  etc. — Labarraque's  solution 
(chlorinated  soda,  IQ  per  cent).  Bichloride  of  mercury  in  solution 
(1:1000).  Permanganate  of  potash  in  solution  (1  ounce  to  a  quart  of 
water).    Formaldehyde  in  solution  (1:200). 

For  Rooms,  Furniture,  Mattresses,  etc. — Fumigation  hy  Formaldehyde 
Gas. — It  may  be  employed  in  concentrated  powdered  form  or  in  pastels. 
For  small  rooms  the  ordinary  Shering  lamp,  which  is  constructed  for 
vaporizing  formaldehyde  pastels  will  suffice.     For  large  hospital  wards. 


PREVENTION    AND    CONTROL   OF   DISEASE  71 

however,  the  ^ ' formaldehyde-potassium-permanganate  method"  is  best. 
It  is  of  advantage  to  use  a  container  consisting  of  a  large  open  vessel 
protected  from  losing  its  heat  by  some  nonconducting  material  such  as 
asbestos.  But  one  can  get  along  almost  equally  as  well  by  using  a  large 
milkpail  set  in  a  wooden  bucket. 

The  infected  room  should  be  made  as  air-tight  as  possible  by  snugly 
closing  the  windows  and  doors  (keyholes,  ventilators,  fireplaces,  etc.) 
by  means  of  cotton  or  cloths.  All  articles  intended  for  disinfection  are 
freely  exposed  (mattresses,  pillows,  boxes  and  drawers  should  be  opened). 

The  fumigating  apparatus  is  placed  in  the  center  of  the  room:  6% 
ounces  of  potassium  permanganate  (for  each  1000  cubic  feet  of  room 
space)  are  put  in  the  container;  and  16  ounces  of  a  40  per  cent  formalde- 
hyde solution  (for  each  1000  cubic  feet  of  room  space)  are  poured  on 
top  of  the  permanganate.  The  operator  now  quickly  leaves  the  room, 
and  closes  the  door  or  window.  The  room  should  remain  tightly  closed 
for  about  ten  hours. 

After  disinfection  the  disagreeable  odor  of  the  formaldehyde  may  be 
removed  by  sprinkling  the  room  with  ammonia  water,  and  thorough 
ventilation. 

Fumigation  with  Sidphur. — The  procedures  are  the  same  as  with  for- 
maldehyde. The  sulphur,  about  3  pounds  for  a  room  10  feet  square, 
is  placed  in  an  iron  pan,  supported  by  bricks  and  set  in  a  tin  vessel  with 
water.  The  sulphur  is  ignited  by  live  coals  or  a  tablespoonful  of  alcohol 
lighted  by  a  match.  Sulphur  fumigation  should  not  wholly  be  depended 
upon  after  grave  epidemic  affections. 

Finally,  it  is  well  to  bear  in  mind  that  sunlight  is  a  disinfectant  of 
great  efficiency,  and  that  prolonged  exposure  to  its  rays  will  materially 
aid  in  rendering  rooms  and  fomites  free  from  infectious  matter. 

III.  IMMUNIZATION— ACQUIRED  IMMUNITY.    BIOLOGIC  DIAG- 
NOSIS AND  THERAPEUTICS 

Medicine  is  rapidly  reaching  the  goal  of  its  highest  ambition,  the 
prevention  and  control  of  communicable  diseases  by  *' Nature's 
method,"  i.e.,  immunization.  Stupid  skepticism  and  boundless  en- 
thusiasm are  gradually  yielding  to  deliberate  experimentation  and 
experience,  and  it  does  not  require  a  very  great  stretch  of  imagination  to 
predict  that  in  the  near  future  every  communicable  affection  will  be 
successfully  resisted  and  combated  by  an  antagonist  evolved  by  the 
causal  microorganism. 

In  order  to  obviate  unnecessary  repetition  we  shall  briefly  describe 
the  biologic  products  at  present  in  use  for  diagnostic,  protective  and 
therapeutic  purposes,  and  the  results  thus  far  achieved. 


72  DISEASES   OF    CHILDREN 

Variola  Vaccine 

With  the  enforcement  of  vaccination  by  all  civilized  nations,  smallpox, 
the  most  loathsome  pestilence,  has  practically  been  eradicated  from  every 
well-regulated  community.  The  principle  of  vaccination  is  the  intro- 
duction into  the  human  body  of  a  weakened  and  harmless  form  of  vac- 
cinia, cowpox,  which  renders  the  system  immune  {i.  e.,  creates  enough 
of  antibodies  to  resist  the  disease)  to  variola.  The  vaccine  is  obtained 
from  the  vesicles  that  form  on  healthy  young  heifers  as  a  result  of  inocu- 
lation with  the  virus  of  cowpox. 

Vaccination 

In  the  absence  of  contraindications  (p.  74)  every  child  of  from  six 
to  twelve  months  old  should  be  vaccinated,  and  revaccinated  about 
seven  years  later.  It  is  preferable  to  vaccinate  at  a  time  when  neither 
excessive  heat  nor  cold  prevails,  i.  e.,  in  May  or  October.  The  left  arm 
at  the  insertion  of  the  deltoid  is  usually  chosen  for  the  vaccination.  In 
girls  the  leg  may  be  preferred  to  avoid  the  possibility  of  an  exposed 
disfiguring  scar.  The  parts  to  be  inoculated  should  be  freely  bared  and 
cleansed  with  soap  and  water  and  thoroughly  dried.  When  one  inocula- 
tion is  to  be  made,  the  epidermis  should  be  abraded  for  about  i/g  inch  in 
diameter  (until  a  serous  exudate  or  a  trace  of  blood  occurs)  by  means 
of  a  sterile  needle ;  when  several  inoculations  are  to  be  made,  they  should 
be  fully  11/2  inches  apart.  About  a  drop  of  vaccine  is  then  gently 
rubbed  into  the  denuded  surface  and  allowed  to  dry.  In  successful 
vaccination  the  inoculated  area  begins  to  redden  and  swell  on  the  third 
or  fourth  day ;  on  the  fifth  day  a  vesicle  appears  which  gradually  changes 
into  an  umbilicated  pustule  surrounded  by  a  red  areola.  The  pustule 
persists  up  to  the  eleventh  or  thirteenth  day  and  then  becomes  covered 
by  a  scab.  The  latter  remains  stationary  for  about  ten  days  longer,  then 
falls  off,  leaving  behind  a  red  scar  which  gradually  becomes  white  and 
glistening  in  appearance.  The  scar  usually  remains  visible  throughout 
life.  Vaccination  is  associated  with  more  or  less  marked  constitutional 
symptoms.  With  appearance  of  the  vesicle  there  is  a  slight  rise  of  tem- 
perature ;  the  child  is  restless,  sleeps  badly,  loses  its  appetite,  and  shows 
other  signs  of  indisposition.  Some  children  react  more  strongly  than 
others,  but  if  the  vaccine  is  pure,  the  vaccinator  clean  and  careful  and 
the  inoculated  area  kept  free  from  irritation  and  infection,  all  the  con- 
stitutional symptoms  disappear  by  the  twelfth  day.  Under  adverse 
circumstances  {e.  g.,  old,  impure  lymph,  defective  asepsis,  constitutional 
diseases)  vaccination  may  be  accompanied  by  very  grave  symptoms. 
The  pustules  may  become  very  large,  the  redness  in  the  vicinity  very 
marked  and  extensive ;  the  axillary  glands  very  much  swollen  and  pain- 


PREVENTION   AND    CONTROL   OF   DISEASE  73 

fill;  tlie  whole  arm  very  strongly  infiltrated;  the  fever  very  high,  up 
to  104°  F. ;  and  convulsions  and  respiratory  and  gastrointestinal  symp- 
toms may  develop.  Suppuration  of  the  glands,  phlegmonous  processes, 
and  even  erysipelas  may  set  in.  Finally,  vaccination  may  be  accom- 
panied by  transient  or  genuine  nephritis,  and  cases  of  scrofula,  tuber- 
culosis and  syphilis  are  on  record — undoubtedly  preexistent,  latent,  but 
awakened  by  the  acute  inflammatory  process.  Occasionally  the  inocu- 
lation wound  fails  to  cicatrize,  continues  to  suppurate,  or  ulcerates. 
Children  with  a  tendency  to  skin  diseases  may  develop  divers  skin  erup- 
tions, such  as  erythema,  eczema,  lichen,  impetigo,  psoriasis,  a  purpura- 
like  eruption  {purpura  vaccinatoria) ,  general  furunculosis,  or,  by  trans- 
ference (autoinoculation)  of  the  vaccine  virus  to  some  diseased  parts  of 
the  skin,  produce  general  vaccinia.  The  latter  may  also  develop-^usu- 
ally  about  the  seventh  or  eight  day — spontaneously,  from  within,  inde- 
pendently of  any  external  influences.  The  lesions,  which  may  be  dis- 
crete or  confluent  (grave),  bear  a  certain  resemblance  to  the  regular 
vaccinal  pox.  In  the  same  manner  the  vaccine  may  be  carried  to  the 
eyes  {vaccine  ophthalmia) ,  and  cause  serious  trouble.  In  fact,  inocula- 
tion pustules  have  been  observed  on  different  portions  of  the  body,  and 
even  on  the  tongue.  Furthermore,  vaccinia  may  also  be  transmitted 
to  other  persons  by  means  of  infected  articles  in  use,  fingers,  bed  sheets, 
bath  water,  sponges,  etc.  Hence  the  importance  of  a  protective  dress- 
ing over  the  vaccination  mark  (clean  sterilized  linen,  sewed  to  the 
sleeve,  changed  every  day)  from  the  time  the  vaccine  has  dried  up  to 
the  falling  off  of  the  scab,  and  of  keeping  the  child's  nails  very  short 
and  its  hands  very  clean.  Bathing  should  be  interrupted  from  the 
fifth  to  fifteenth  day.  Moist  boric  acid  dressings  are  useful  to  re- 
duce the  severe,  local  inflammatory  process,  and  where  the  latter  is 
grave,  and  the  itching  intense,  a  continuous,  moist  dressing  with  ni- 
trate of  silver  (^4=  per  cent)  will  prove  especially  beneficial.  In  de- 
layed healing  the  wound  should  be  cauterized  with  a  5  per  cent  to  10 
per  cent  solution  of  nitrate  of  silver,  and  dressed  like  any  other 
wound.  Other  complications  arising  should  be  treated  according  to 
indications. 

Revaccination. — As  already  suggested  revaccination  should  be  per- 
formed about  seven  years  after  the  first  vaccination,  a  period  of  time 
after  which  the  immunity  against  smallpox  usually  ceases.  In  case  of 
epidemics  revaccination  should  be  resorted  to  more  frequently.  Re- 
vaccination is  also  indicated  to  modify  an  attack  of  smallpox.  In  suc- 
cessful revaccination  the  local  and  systemic  manifestations  are  essen- 
tially the  same  as  after  the  first  vaccination  except  that  they  are  much 
milder  in  form. 


74  DISEASES   OF    CHILDREN 

Contraindications  to  Vaccination. — It  is  not  advisable  to  vaccinate 
infants  under  three  months,  and  children  of  all  ages  who  are  suffering 
from  severe  acute  and  recurrent  skin  affections,  local  or  general  syphilitic 
or  tuberculous  (scrofular)  lesions,  and  great  debility. 

Schick's  Reaction*  for  Detection  of  Susceptibility  to  Diphtheria. — 
The  outfit  of  the  New  York  Health  Department  for  the  Schick  re- 
action consists  of  a  capillary  tube  (containing  two  minimum  lethal 
doses  for  the  guinea-pig  of  undiluted  diphtheria  toxin)  and  a  small 
rubber  bulb,  and  a  bottle  filled  with  10  c.c.  sterile  physiologic  salt 
solution  (with  0.025  per  cent  carbolin  acid).  A.  Zingher  gives  the 
following  directions  for  its  use:  Break  off  one  end  of  the  capillary 
tube  and  push  it  carefully  through  the  neck  of  the  rubber  bulb  until 
it  punctures  the  diaphragm  within  and  enters  the  cavity  of  the  bulb ; 
then  break  off  the  other  end  of  the  tube.  Hold  the  bulb  between 
thumb  and  middle  finger ;  place  the  index  finger  on  the  opening  of  the 
outer  end  of  the  bulb  and  expel  the  toxin  in  the  saline  solution.  Rinse 
out  the  capillary  tube  by  repeatedly  drawing  up  saline  and  expelling 
it  into  the  bottle,  then  cork  the  bottle  and  shake  the  diluted  toxin. 
Inject  exactly  0.15  c.c.  of  the  solution  (representing  1/50  minimum 
lethal  dose  for  the  guinea  pig)  intracutaneously  on  the  flexor  surface 
of  the  forearm  or  arm.  The  injection  is  made  with  an  all-glass  syr- 
inge and  fine  needle.  Instead  of  a  syringe  Koplik  and  Unger  have  de- 
vised a  hypodermic  shaped  needle  (with  a  handle)  which  is  dipped  into 
the  undiluted  toxin  and  introduced  intradermically.  In  the  absence 
of  antitoxin  in  the  child 's  blood,  or  in  the  presence  of  only  a  very  minute 
amount,  insufficient  for  protection  against  diphtheria,  a  circumscribed 
area  of  redness  and  infiltration,  from  i/^  to  2  cm.  in  diameter  appears 
on  the  skin  in  from  twenty-four  to  forty-eight  hours,  and  persists  for 
about  a  week  leaving  behind  a  brownish  pigmentation.  The  positive  re- 
action should  not  be  mistaken  for  a  pseudoreaction  (which  is  due  to 
proteins)  that  occasionally  appears  after  the  test.  The  pseudoreaction 
is  earlier  in  its  appearance  as  well  as  disappearance  and  is  more  infil- 
trated than  the  genuine  reaction.  About  40  to  50  per  cent  of  the  chil- 
dren react  positively  to  the  toxin  test.f    All  those  who  do  so  and  are  ex- 


*Discovered  by  Dr.   Schick  of  Vienna  in   1912. 

■^ Susceptibility   of   Various  Ages  to  Diphtheria 

(as   indicated  by  the   Schick  diphtheria-toxin   skin  test.) 

Age  Susceptible 

Under    3    months    15  per  cent 

3   to   6   months    30  per  cent 

6  months  to   1  year   60  per  cent 

1  to  2  years    60  per  cent 

2  to    3    years    60  per  cent 

3  to   5    years    40  per  cent 

S    to    10  years    30  per  cent 

10  to   20  years    20  per  cent 

Over    20    years    12  per  cent 


PREVENTION    AND    CONTROL    OP    DISEASE  75 

posed  to  diphtheria  infection,  should  immediately  receive  a  prophylac- 
tic dose  of  diphtheria  antitoxin.  The  test  is  also  very  valuable  in  scar- 
latina to  determine  the  child's  susceptibility  to  diphtheria,  which  forms 
so  frequent  a  complication  during  the  course  of  the  disease. 

Antidiphtheritic  Serum 

Diphtheria  antitoxin  is  the  purified  blood-serum  of  a  horse  that  has 
been  rendered  immune  to  diphtheria  by  a  long  course  of  treatment 
with  diphtheria  toxin.  It  is  specific  in  its  effects,  having  lowered  the 
high  (40  to  60  per  cent)  mortality  from  diphtheria  to  about  5  per  cent 
— if  administered  early  and  in  ample  quantity.  Furthermore,  those 
exposed  to  diphtheria  almost  invariably  escape  infection  by  timely 
administration  of  the  serum.  It  is  practically  harmless  if  free  from 
admixture  of  virulent  bacteria,  and  with  introduction  of  the  concen- 
trated, high-grade  preparations  and  the  application  of  greater  care 
in  handling  and  administration,  the  numerous  disagreeable  accompani- 
ments (fever,  multifarious  eruptions,  articular  swellings,  etc.)  have 
ceased  to  be  as  common  and  as  severe  as  in  former  years. 

The  dose  of  antitoxin  for  ordinary  cases  of  diphtheria  should  be 
2,000  units  for  every  year  of  the  child 's  age  up  to  five  years,  and  10,000 
units  as  the  average  dose  for  older  children.  If  urgent,  the  injections 
may  be  repeated  once  or  twice  at  intervals  of  from  six  to  twelve  hours. 
Malignant,  especially  laryngeal,  cases  require  double  doses.  For  pro- 
tective purposes  a  third  of  the  ordinary  dose  usually  suffices.  The  pro- 
tection usually  lasts  from  four  to  six  weeks. 

The  antitoxin  is  administered  by  a  sterile  hypodermic  syringe  (or 
the  mercantile  serum-containing  syringes)  by  deep  injection  into  the 
anterior  surface  of  the  abdomen  or  thorax  or  outer  surface  of  the 
thigh,  which  are  rendered  aseptic  by  soap,  water,  ether  and  alcohol, 
or  tincture  of  iodine.  The  point  of  injection  is  subsequently  sealed 
by  sterile  adhesive  plaster. 

Diphtheria  Toxin-Antitoxin  Immunization 

During  the  last  year  the  Department  of  Health  of  the  city  of  New 
York  has  placed  at  the  disposal  of  the  profession  the  aforementioned 
product  for  the  purpose  of  effecting  permanent  immunity  in  persons 
susceptible  to  diphtheria  as  demonstrable  by  Schick's  reaction. 

"The  usual  injection  for  all  ages  is  approximately  400  times  the 
fatal  dosef  for  a  half-grown  guinea  pig,  to  which  has  been  added  just 

tA.  Zingher  (Jour.  Am.  Med.  Assn.,  Nov.  13,  1920)  found  that  quite  a  number  of  Schick 
test-outfits  furnished  by  commercial  laboratories  do  not  contain  a  sufficient  amount  of  toxin. 


76  DISEASES   OF   CHILDREN 

sufficient  antitoxin  to  neutralize  it.  This  is  about  four  units  of  anti- 
toxin. The  injection  usually  contains  1  c.c.  of  fluid  and  is  made  sub- 
cutaneously.  The  mixture  is  tested  very  carefully  for  its  harmlessness 
before  being  used,  and  if  so  tested  is  absolutely  safe.  As  it  ages,  the 
toxin  disappears  more  rapidly  than  the  antitoxin.  A  second  and  third 
injection  of  the  same  amount  made  at  weekly  intervals  add  greatly 
to  the  quantity  of  the  antitoxin  development  from  the  first  injection. 

The  Local  and  Constitutional  Reaction 

"The  diphtheria  toxin-antitoxin  mixture  contains  besides  the  neutral- 
ized toxin  a  considerable  amount  of  protein  substance.  This  is  partly 
formed  of  the  proteins  originally  present  in  the  broth  in  which  the 
bacilli  were  grown  and  partly  from  the  remains  of  broken  down  or  di- 
gested bacilli  in  the  cultures.  The  reaction  to  the  protein  in  the  injec- 
tion is  similar  to  the  reaction  to  the  typhoid  vaccine  but  it  is  of  less 
severity. 

*  *  The  element  of  age  is  very  important.  The  infant  shows  in  the  great 
majority  of  cases  neither  a  local  nor  a  constitutional  reaction,  while 
grown  up  children  and  adults  exhibit  in  perhaps  30  per  cent  of  the  cases 
considerable  local  swelling  and  more  or  less  definite  constitutional 
disturbance.  Within  24  to  72  hours  all  disturbance  is  over.  No  lasting 
deleterious  results  have  occcurred.  Children  of  ages  between  one  and 
ten  years  vary  in  the  amount  of  reaction  according  to  their  age.  The 
youngest  shows  the  least  and  the  oldest  the  most. 

The  Immunization  Response  in  Susceptible  Children 

"Those  persons  who  are  naturally  immune  against  diphtheria  are 
usually  so  from  having  antitoxin,  but  may  be  so  from  the  possession  of 
other  protective  substances.  The  antitoxin  we  can  measure  by  the  Schick 
test,  but  we  have  no  practical  way  to  detect  bactericidal  substances. 

The  Immunizing  Results 

"These  are  measured  by  the  percentage  of  susceptible  persons  who  be- 
come immune,  and  by  the  persistence  of  the  immunity.  The  antitoxin  de- 
velops slowly  after  the  injections  are  begun  and  gradually  increases.  In 
only  a  few  cases  does  an  appreciable  amount  of  antitoxin  develop  in  less 
than  three  weeks  after  the  first  injection.  The  majority  respond  during 
the  second  month.  There  are  a  few  who  become  fully  immune  only  dur- 
ing the  sixth  month.  The  results  in  529  children  who  were  carefully  ob- 
served were  as  follows: 


PREVENTION   AND  CONTROL    OF   DISEASE                                      77 

Number  of  Doses  No.  of  Children  Im-      -p            .  j 

of  I  c.e.  Toxin-            No.  of  Children  mune  Three  Months      ^f^  %V^      IT'l*; 

Antitoxin  after  Injection        ^^t^'*  ^^''^^  ^«"t^^« 


1 

239 

175 

73 

2 

89 

80 

90 

3 

201 

191 

95 

"These  figures  approximately  agree  with  our  results  in  thousands  of 
cases.  In  young  infants  who  are  still  retaining  their  parents'  antitoxin, 
transferred  to  them  passively  before  birth,  we  have  less  successful  results. 
Tested  one  year  afterwards  only  about  fifty  per  cent  were  found  to  be 
immune.  This  percentage  is  about  twice  as  great  as  among  those  not 
treated.  Some  2,400  infants  of  an  age  under  one  week  have  been  injected 
with  absolutely  no  bad  effect."  Similar  observations  were  made  by  J. 
Blum  in  an  Infant  Asylum  accommodating  1,076  children.* 

"The  inmates  of  two  institutions  in  New  Jersey  have  been  Schick 
tested  for  the  fifth  time  for  immunity  to  diphtheria,  after  one  active  im- 
munization with  toxin-antitoxin.  The  children  were  found  to  have  re- 
mained immune  from  four  to  four  and  a  half  years.  This  is  the  longest 
period  over  which  such  tests  have  been  made,  so  far  as  is  known.  The 
Leake  and  Watts  Home,  in  New  York,  was  also  tested  and  the  few  chil- 
dren remaining  in  the  home,  since  the  first  test  four  years  ago,  were 
found  to  be  still  immune. 

"The  4,500  inmates  of  the  State  Insane  Asylum  at  Kings  Park  have 
been  Schick  tested  for  immunity  to  diphtheria,  and  all  patients  showing 
susceptibility  immunized  by  toxin-antitoxin. 

"The  children  at  the  Colored  Orphan  Asylum  at  Riverdale-on-the- 
Hudson,  who  had  previously  received  toxin-antitoxin,  have  been  retested 
by  the  Schick  test.  The  result  shows  that  104,  out  of  the  111  children 
injected,  have  developed  active  immunity  to  diphtheria." 

Antitetanic  Serum 

Like  diphtheria  antitoxin,  antitetanic  serum  is  obtained  from  the 
blood  of  horses  previously  immunized  to  the  toxin  of  the  tetanus 
bacillus.  Its  efficacy  as  a  curative  remedy  is  as  yet  awaiting  indis- 
putable demonstration,  but  its  value  as  a  preventive  of  tetanus  is 
authoritatively  established.  Whenever  there  is  reason  to  fear  tetanus 
infection  (e.  g.,  contused  or  lacerated  wounds — toy-pistol  wounds — 
soiled  with  earth  or  other  foreign  matter)  especially  when  an  unusu- 
ally large  number  of  tetanus  cases  prevail,  it  is  imperative  promptly  to 
administer  tetanus  antitoxin  as  a  prophylactic  measure. 


*Active  Immunization  Against  Diphtheria  in  a  Large  Child-Caring  Institution,  Am.  Jour.  Dis. 
Child.  July,   1920. 


78  DISEASES   OF    CHILDREN 

Tetanus  antitoxin  is  usually  administered  intraspinally,  intravenously, 
and  subcutaneously  in  doses  of  1,000  to  1,500  units;  the  dose  is  repeated 
as  a  preventive  measure  after  ten  days,  as  a  curative  (3,000  to  5,000 
units)  once  a  day.     (See  p,  227.) 

Antimening-itis  Serum  (Flexner) 

This  serum  acts  specifically  in  cerebrospinal  meningitis  due  to  the 
diplococcus  intracellularis  (Weichselbaum)  only.  If  used  by  the  sub- 
dural and  intravenous  methods  in  suitable  doses,  promptly  and  at 
proper  intervals,  it  is  capable  of  greatly  diminishing  the  fatality  gen- 
erally due  to  the  disease;  of  reducing  the  period  of  illness,  and,  in  a 
large  measure,  of  preventing  the  chronic  lesions  and  types  of  the 
affection. 

After  reducing  the  intracerebrospinal  pressure  by  withdrawal,  by 
lumbar  puncture  (Fig.  175),  of  about  30  to  60  c.c.  of  cerebrospinal  fluid, 
we  inject  30  c.c.  of  the  serum  into  the  spinal  canal  by  means  of  an 
antitoxin  syringe  or  by  gravity  through  a  funnel  and  rubber  tube 
attached  to  the  puncture  needle.  The  modern  serum  containers 
greatly  facilitate  the  administration  of  the  serum.  The  injection  is 
repeated  daily  for  three  or  four  days  or  longer  until  the  diplococci 
disappear.  In  fulminating  cases  a  second  dose  may  be  given  after  the 
lapse  of  twelve  hours.  If  after  a  period  of  apparent  recovery  the 
symptoms  recur  and  the  diplococci  reappear,  the  injection  should 
be  repeated.  The  serum  is  practically  useless  in  cerebrospinal  menin- 
gitis after  the  condition  of  hydrocephalus  has  supervened. 

"Up  to  a  short  time  before  the  war  began  a  single  type  of  meningococ- 
cus was  generally  accepted  as  the  cause  of  epidemic  meningitis.  Dopter^ 
was  the  first  to  classify  meningococcus-like  organisms  into  distinct  types. 
In  connection  with  a  recent  very  lucid  description  of  the  manner  in 
which  the  types  of  meningococcus  came  to  be  recognized,  he^  has  de- 
scribed in  detail  the  modifications  which  have  resulted  in  the  treatment 
of  meningitis.  Four  types  of  meningococci  are  now  generally  recognized, 
designated  as  Types  A,  B,  C  and  D.  Type  A  appears  to  have  been  the 
common  one  before  the  war,  being  found  according  to  Dopter  in  from  95 
to  96  per  cent  of  the  cases.  Of  the  other  types,  sometimes  called  para- 
meningococci,  B  is  most  common,  C  and  D  exceptional.  Infections  by 
Type  B  increased  during  the  first  two  years  of  the  war,  and  at  the  end 
of  1917  about  50  per  cent  of  the  cases  in  the  French  army  were  of  this 
form.  Each  of  these  various  types  of  organism  is  affected  only  by  its 
own  specific  serum,    A  case  of  meningitis  caused  by  the  Type  B  Meningo- 


iDopter,    C:     Recent    Work    on    Cerebrospinal    Fever,    Lancet,    French    Supplement,    1:1075. 
(June  21)    1919. 


PREVENTION    AND    CONTROL    OF   DISEASE  79 

COCCUS  is  not  influenced  by  a  serum  prepared  from  Type  A  organisms. 
Consequently  it  has  been  necessary  to  prepare  serums  from  each  type 
of  organism  for  use  in  the  treatment  of  meningitis  due  to  the  correspond- 
ing type. 

"For  tlie  most  efficient  serum  treatment  of  epidemic  meningitis,  two 
things  now  appear  essential:  (1)  an  accurate  biologic  determination  of 
the  type  of  organism  concerned  in  the  individual  case,  and  (2)  the 
administration  of  the  serum  prepared  from  the  corresponding  type. 
Doptor  is  not  in  favor  of  using  polyvalent  serum  except  as  a  measure 
of  precaution  until  the  laboratory  examination  has  determined  the  type 
present  in  the  case.  As  soon  as  the  type  is  known,  the  corresponding 
monovalent  serum  should  be  substituted.  He  believes  that  'too  much 
polyvalency  might  conceivably  involve  risk  of  diminished  potency. '  Those 
who  have  treated  meningitis  with  serum  have  observed  that  occasionally 
cases  occur  which  are  not  appreciably  benefited  by  the  polyvalent  serum 
used,  and  in  such  cases  the  spinal  fluid  does  not  clear  up  neither  do  the 
meningococci  decrease  in  the  fluid,  as  is  usual  in  most  cases.  Sometimes 
another  make  of  polyvalent  serum  may  be  active,  and  it  is  advised  to 
make  use  of  this  expedient,  with  the  hope  that  a  strain  of  meningococcus 
corresponding  to  the  one  causing  the  infection  may  have  been  among 
those  employed  in  preparing  the  serum.  At  best  this  is  not  satisfactory. 
It  is  much  to  be  desired  that  serums  should  be  prepared  from  the  several 
types  so  that  they  may  be  available  for  cases  which  do  not  respond 
promptly  to  the  polyvalent  serums.  Accurate  differentiation  of  the 
type  of  infecting  organism  by  biologic  tests  is  essential  before  the  treat- 
ment can  be  carried  out  with  a  high  degree  of  precision.  It  has  been 
found  that  the  cases  prevailing  in  a  group  of  individuals  both  in  the 
meningeal  exudate  and  in  the  nasopharynx  of  carriers  are  usually  of  one 
type.  Mathers  and  Herrold  found  that,  in  a  camp  near  Chicago,  almost 
86  per  cent  of  the  cases  of  meningitis  were  due  to  Type  A  (Group  1), 
and  in  the  city  of  Chicago  at  the  same  time  more  than  86  per  cent  of 
the  cases  were  due  to  Type  B  (Group  2).  If  investigation  revealed  the 
prevalence  of  one  type  in  a  community  or  epidemic,  a  serum  high  in  im- 
mune bodies  for  that  type  would  be  reasonably  used  for  routine  treatment 
if  it  were  not  feasible  to  make  a  biologic  differentiation  in  each  case.  As 
the  abnormal  conditions  of  army  camps  disappear,  it  will  be  of  interest  to 
note  whether  the  prevailing  type  of  meningococcus  will  again  be  the  Type 
A,  as  was  apparently  the  case  before  the  war.  Study  of  cases  of  epidemic 
meningitis  has  served  also  to  emphasize  the  fact  that  the  meningococci 
are  found  not  only  in  the  meninges,  but  also  often  in  the  blood,  joints, 
etc.  When  serum  is  injected  intraspinally,  it  rapidly  passes  into  the 
circulation ;  but  it  is  desirable  to  secure  a  greater  concentration  of  anti- 


80  DISEASES   OF    CHILDREN 

bodies  in  the  blood  than  is  secured  in  this  way.  This  can  be  brought 
about  by  intravenous  or  intramuscular  injection  of  serum.  It  would 
probably  be  a  useful  practice  to  combine  intramuscular  with  intraspinal 
injection  in  all  eases.  When  intravenous  injections  are  used,  all  pre- 
cautions to  avoid  anaphylactic  shock  should  be  taken."  (Jour.  Am. 
Med.  Assn.,  Oct.  11,  1919.) 

With  the  demonstration  of  the  meningococcus  in  the  blood,  sev- 
eral clinicians  have  recently  begun  to  administer  antimeningococcus 
serum  intravenously  as  well  as  intraspinally.  The  intravenous  method 
is  recommended  especially  in  severe  cases.  Major  W.  W.  Herrick,  who 
has  had  under  observation  265  cases  of  epidemic  cerebrospinal  menin- 
gitis, at  Camp  Jackson,  and  has  employed  this  method  with  a  great 
reduction  in  the  ordinary  mortality  in  this  affection,  offers  the  fol- 
lowing suggestions  which  relate,  of  course,  to  adults,  but  can  readily  be 
modified  to  suit  the  needs  of  children : 

Important  Points  in  Intravenous  Serum  Treatment. — It  must  be 
employed  with  boldness,  yet  with  care.  One  must  be  prepared 
to  give  from  four  to  eight  massive  injections  by  vein  of  from 
80  to  150  c.c.  during  the  acute  stages  of  the  disease  or  a  period 
of  from  two  to  four  days.  There  is  much  more  danger  in  insufficient 
than  in  excessive  intravenous  serum  administration.  He  has,  in  fact, 
in  128  cases  so  treated,  had  no  serious  serum  effects.  His  regrets  have 
been  that  serum  was  not  more  freely  used  in  many  of  the  early  cases. 

The  desensitization  by  subcutaneous  injection  of  1  c.c.  of  serum  one 
hour  before  the  introduction  of  serum  into  the  vein  and  the  cautious 
injection  of  the  first  15  c.c.  at  the  rate  of  1  c.c.  per  minute  are  the 
secrets  of  safe  intravenous  serum  therapy.  Immediate  stopping 
of  the  injection  with  the  appearance  of  dyspnea,  pallor,  cyanosis, 
vomiting,  weak,  rapid  or  irregular  pulse  or  other  immediate  serum 
effects  is  essential.  Renewal  of  the  attempt  after  two  or  three  hours 
is  rarely  unsuccessful.  Even  those  patients  thoroughly  sensitized  to 
serum  by  earlier  courses  of  treatment  can  be  treated  safely  with  these 
precautions. 

In  those  prolonged  cases  in  which  meningococci  persist  in  the  spinal 
fluid  and  in  which  the  patients  are  made  uncomfortable  by  intraspinal 
injections,  showing  increased  opisthotonos,  and  severe  pain  in  the 
head  or  back  or  lower  extremities  following  the  treatment,  it  is  better 
to  omit  all  interference.  At  times  drainage  may  be  necessary  with 
or  without  further  intravenous  injections.  Many  of  these  prolonged 
cases  apparently  become  intolerant  of  intraspinal  serum  injections. 
If  satisfactory  response  does  not  follow  a  series  of  eight  or  ten  intra- 
spinal treatments,  it  is  generally  best  to  cease  injecting  serum  intra- 


PREVENTION   AND    CONTROL   OF   DISEASE  81 

spinally,  continuing  drainage  only  if  there  is  discomfort  from  increased 
intracranial  pressure  or  apparent  danger  of  blocking  the  foramina. 

In  relapsing  cases  the  entire  cycle  of  treatment  must  be  repeated 
with  the  same  thoroughness  and  care  used  in  the  initial  course.  The 
organism  cultivated  from  the  blood  or  spinal  fluid  may  be  used  to 
determine  the  presence  of  agglutinins  in  the  serum  employed.  Valua- 
ble evidence  can  thus  be  obtained  as  to  the  specificity  of  the  serum  for  the 
strain  of  meningococcus  present.  This  is  of  the  highest  importance. 
Therapeutic  results  seem  to  parallel  the  agglutinin  content  of  the  serum 
for  the  special  strain  of  meningococcus  involved.  Commercial  serums 
are  frequently  lacking  in  high  agglutinin  content,  and  their  therapeu- 
tic effect  is  often  disappointing.  In  the  absence  of  desirable  results 
from  a  given  serum,  use  should  promptly  be  made  of  serum  from  an- 
other source.  This  may  be  of  vital  moment  to  the  patient.  The  stand- 
ardizations of  serums  by  governmental  authority  is  an  urgent  need. 

Of  course,  the  dosage  varies  with  the  age  of  the  patient.  A  third 
of  the  adult  dose  ought  ordinarily  to  suffice  for  children  under  five  years 
of  age,  and  one-half  of  the  adult  dose  for  older  children.  In  young 
infants  the  longitudinal  sinus  route  may  be  used  for  the  injection  of 
the  serum ;  in  older  children  the  basilic  vein. 

Several  other  sera  {e.g.,  antipneumococci,  antidysenteric)  are  now  on 
the  market.     Their  curative  merits,  however,  are  still  unestablished. 

Bacterial  Vaccines 

Following  upon  the  great  researches  of  our  contemporary  pathol- 
ogists, bacteriologists  and  clinicians,  A.  E.  Wright,  of  London,  has  dem- 
onstrated the  remarkable  fact  that  emulsions  of  dead  bacteria — bac- 
terial vaccines  so  called — if  injected  subcutaneously  increase  chemo- 
taxis  and,  therefore,  phagocytosis.  The  molecular  group  produced 
by  the  presence  of  the  killed  bacteria  in  the  blood  that  renders  the 
living  bacteria  of  the  same  species  a  ready  prey  to  the  phagocytes 
he  designated  "opsonin,"  corresponding  to  the  Greek  verb  "opsono" 
— ^I  cater  for,  I  prepare  victuals  for.  He  also  devised  a  method  to 
determine  the  "opsonic  index,"  of  sensitizing  power  of  the  blood, 
so  that  in  a  given  case  of  infection  one  can,  as  it  were,  measure  the 
opsonin  content  of  the  blood  and  increase  it,  if  found  below  par. 

Bacterial  vaccine  therapy  is  mostly  limited  to  local  infections,  e.  g., 
furunculosis,  phlegmons,  carbuncles,  where  the  offending  microor- 
ganisms can  readily  be  determined  by  microscopic  examination  of  the 
discharges,  and  accordingly  the  vaccine  chosen  to  meet  the  indications. 

Of  the  numerous  vaccines  thus  far  recommended,  the  staphylococcus 


82  DISEASES   OF    CHILDREN 

and  streptococcus  vaccines  have  actually  stood  the  test  and  proved 
of  great  utility.    They  are  deserving  of  more  general  application. 

Favorable  results  are  .also  on  record  from  the  use  of  vaccines  pre- 
pared from  the  bacillus  coli  (in  colicystitis) ;  from  gonococci  (in  gonor- 
rheal affections,  especially  vulvovaginitis) ;  from  typhoid  bacilli  (in 
typhoid,  especially  as  a  preventive  measure)  and  from  combined  pertussis 
vaccine  (as  a  preventive,  and  in  the  early  stages  of  whooping-cough  as 
a  therapeutic  measure.    See  ''Pertussis"). 

The  inoculations  are  given  by  means  of  a  sterile  hypodermic  syr- 
inge, in  the  same  manner  as  antitoxin.  In  children  particularly  it  is 
advisable  to  begin  with  small  doses,  let  us  say,  50  million  staphylococci, 
or  2  million  streptococci,  and  to  increase  the  dose  of  each  succeeding 
injection. 

In  order  to  obtain  prompt  results  it  is  essential  to  know  not  only 
the  specific  infecting  microorganism  but  also  its  variety;  for  instance, 
whether  the  offending  staphylococcus  is  an  aureus,  albus,  or  citreus, 
since  the  employment  of  a  different  variety  of  vaccine  is  apt  to  prove 
useless.     For  Influenza  Vaccines  see  p.  354, 

Bacterial  vaccines  are  often  prepared  directly  from  cultures  obtained 
from  the  individual  to  be  treated — autogenous  vaccine. 

Tuberculin  Tests  and  Tuberculins 

These  bacterial  products  are  invaluable  in  the  early  diagnosis  of 
tuberculosis  in  children.  By  means  of  tuberculin  we  are  enabled  to 
detect  from  90  to  95  per  cent  of  cases  of  tuberculosis,  often  at  a  time 
when  no  other  clinical  manifestations  or  bacteriologic  examinations 
indicate  its  presence.  It  has  furthermore  the  great  advantage  that 
its  use  calls  for  no  complicated  procedures,  methods,  calculations  or  in- 
struments. According  to  von  Pirquet,  the  specific  test  is  based  upon 
the  fact  that  an  individual  contracting  tuberculosis  develops  a  hyper- 
sensitiveness  of  the  tiSvSues  (so-called  "allergia")  to  the  poison  of  tu- 
bercle bacilli  which  is  manifested  by  a  local  inflammation  or  systemic 
disturbance. 

The  tuberculin  reaction  may  be  elicited  in  the  following  manner : — 
1,  The  Cutaneous  Method  (von  Pirquet). — After  cleansing  the  ante- 
rior surface  of  the  forearm  with  soap,  water  and  ether,  two  small  abra- 
sions (as  for  vaccination)  or  punctures  of  the  skin  are  made  at  an  inter- 
space of  about  2  inches.  On  one  of  the  two  abraded  spots  a  drop  of  a 
50  to  100  per  cent  solution  of  old  TB  is  applied  and  allowed  to  dry. 
If  tuberculosis  is  present,  a  red  pea-  to  bean-sized  papule  appears  after 
from  twenty-four  to  forty-eight  hours  at  the  point  of  contact  of  the 


PREVENTION    AND    CONTROL   OF   DISEASE  83 

injured  skin  and  tuberculin,  while  the  other  nontuberculized  .spot  re- 
mains free  from  the  inflammatory  reaction. 

2.  Conjunctival  Method  (Calmette). — A  drop  of  i/o  to  1  per  cent  (try- 
ing the  weaker  solution  first)  of  old  TB  solution  is  instilled  into  the  con- 
junctival sac  of  one  eye.  In  the  presence  of  tuberculosis  a  positive  re- 
action is  manifested  within  twenty-four  hours  by  reddening  of  the 
caruncles  and  semilunar  fold  of  the  conjunctiva  and  injection  of  the 
corneal  conjunctiva.     The  other  eye  remains  normal. 

3.  Nasal  Method  (Wolff -Eisner  and  Calmette). — A  cotton  tampon  sat- 
urated with  a  1  per  cent  TB  solution  is  applied  against  the  nasal  septum 
and  allowed  to  remain  there  for  about  ten  minutes.  In  from  eighteen  to 
forty-eight  hours  a  peculiar  exudation  appears  which  dries  and  forms 
a  yellow  crust  upon  a  congested  mucosa.  From  this  clumps  of  extrav- 
asated  red  cells  project  here  and  there  as  minute  reddish  points.  The 
crust  generally  falls  oft'  in  from  four  to  six  days. 

4.  Percutaneous  Method  (Moro). — This  method  is  less  reliable  than 
the  aforementioned  procedures.  A  50  per  cent  tuberculin  ointment  is 
rubbed  over  about  a  square  inch  of  epidermis  until  absorbed.  If  the 
reaction  is  positive,  papules  appear  within  from  twenty-four  to  forty- 
eight  hours. 

5.  Subcutaneous  Method. — ^Very  rarely  employed  in  young  children. 
Tuberculin  Therapy. — Tuberculin  treatment,  like  so  many  similar 

new,  in  their  therapeutic  effects  grossly  inflated,  remedial  measures, 
has  for  several  years  been  relegated  into  oblivion.  Yet  tuberculin, 
properly  employed  and  in  suitable  cases  is  of  remarkable  benefit  in  tu- 
berculous affections,  more  particularly  in  those  of  the  small  bones, 
joints,  glands  and  skin.  Its  curative  action  is  due  to  stimulation  of  de- 
fensive powers  of  the  body  and  its  resistance  to  the  pathogenic  action 
of  the  tubercle  bacillus  and  its  toxin.  If  these  means  of  defense  are 
not  in  a  condition  to  be  favorably  influenced  by  the  tuberculin,  the 
therapeutic  results,  of  course,  will  be  nil.  Hence  the  importance  of  be- 
ginning the  treatment  as  soon  as  tuberculosis  is  diagnosed  or  even  sus- 
pected (E.  Beraneck).  Furthermore,  the  important  thing  is  to  begin 
with  a  small  dose  of  a  very  dilute  solution,  and  to  continue  to  inject 
(twice  a  week)  three  or  four  times  at  least  before  arriving  at  any 
definite  estimate  of  the  need  of  a  larger  dose.  If  the  effect  seems 
favorable,  the  same  dosage  should  be  continued  for  weeks  or  months, 
so  long  as  the  patient  is  deriving  benefit  from  the  treatment.  On  the 
other  hand,  if  three  or  four  injections  of  the  initial  small  dose  seem  to  ex- 
ert no  beneficial  effect,  a  somewhat  larger  dose  is  administered  and 
its  therapeutic  action  carefully  observed  in  the  same  manner  as  with 
the  smaller  dose.    The  initial  dose  of  the  tuberculin  solutions,  presently 


84 


DISEASES  OF   CHILDREN 


to  be  enumerated,  should  be  one-millionth  of  a  milligram  in  non- 
febrile  cases  and  a  smaller  dose  in  those  showing  moderate  fever. 
The  subcutaneous  injection  is  made  with  the  usual  aseptic  precautions. 
If  the  injection  is  followed  by  marked  systemic  disturbance  and 
high  fever,  the  treatment  is  temporarily  discontinued  and  a  smaller 
dose  begun  with,  after  the  fever  has  subsided. 

The  tuberculin  (Koch)  is  diluted  with  sterile  physiologic  salt  solu- 
tion or  ^  per  cent  carbolic  acid  water  in  the  following  manner: 


Sol.  No. 

1 

Tuberculin 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.1 

Sol.  No. 

2 

Sol.  No.  1 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.01 

Sol.  No. 

3 

Sol.  No.  2 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.001 

Sol.  No. 

4 

Sol.  No.  3 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.0001 

Sol.  No. 

5 

Sol.  No.  4 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.00001 

Sol.  No. 

6 

Sol.  No.  5 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.000001 

Sol.  No. 

7 

Sol.  No.  6 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.0000001 

Sol.  No. 

8 

Sol.  No.  7 
Diluent 

1 
9 

c.c. 
c.c. 

1  c.c. 

0.00000001 

Sol.  No. 

9 

Sol.  No.  8 

1 

c.c. 

1  c.c. 

0.000000001 

Complement-Fixation  Reaction  in  Tuberculosis 

During  the  last  ten  years  considerable  progress  has  been  made  in 
the  detection  of  tuberculosis  by  the  aforementioned  reaction.  The 
technie  is  the  same  as  in  the  Wassermann  reaction  (q.  v.)  except  for 
the  antigen,  which  consists  of  an  emulsion  of  ground  tubercular  bacil- 
lary  bodies.  The  longer  the  bacilli  are  ground,  the  better  the  antigen. 
It  matters  but  little  whether  the  bacilli  are  triturated  dry  (Miller), 
wet  (Fleischer),  by  boiling  in  glycerin  (Petroff)  by  dissolving  off  the 
wax  and  suspending  (Cooke,  Wilson),  or  allowing  it  to  occur  by  lysis 
(Corper).  From  a  careful  experience  with  6500  tests,  W.  W.  Watkins 
and  C.  N.  Boynton*  have  recently  formulated  the  following  conclu- 
sions : 

The  Miller  antigen  is  serviceable,  practical  and  efficient  for  the  com- 
plement-fixation test  in  tuberculosis. 

The  reaction  is  specific  for  tuberculosis  and,  when  positive,  should 
be  interpreted  as  indicating  tuberculosis  of  some  degree  of  activity. 
When  the  Wassermann  and  tuberculosis  fixation  reactions  are  both 
positive,  they  should  be  interpreted  without  relation  to  each  other. 

The  positive  fixation  reaction  can  be  interpreted  as  indicating  tuber- 


•Jour.  Am.  Med.  Assn.,  Oct.  2.   1920. 


PREVENTION    AND    CONTROL   OP   DISEASE  85 

culosis,  either  active  at  the  time,  or  recently  active.  The  focus  may 
or  may  not  be  of  clinical  significance,  which  fact  must  be  determined 
by  other  means. 

The  negative  fixation  reaction  indicates  either  absence  of  infection, 
excessive  activity  of  the  disease,  exhausting  the  antibody,  or  arrest 
of  the  disease  with  spontaneous  disappearance  of  antibody  no  longer 
required. 

Serum  Diagnosis  of  Syphilis  (Wassennann) 

The  substances  employed  in  this  reaction  are  as  follows:  (1)  Com- 
plement, One  to  ten  dilution  of  fresh  guinea  pig  serum  in  normal 
(0.85  per  cent)  salt  solution.  (2)  Antigen.  Alcoholic  extract  of  a 
syphilitic  organ  or  suspension  of  an  organ  in  weak  carbolic  acid  solu- 
tion (1  per  cent).  (3)  Amboceptor.  Inactivated  serum  of  rabbit 
which  has  been  highly  immunized  against  sheep  red-cell  by  five  or  six 
injections  of  increasing  amounts  of  sheep  red-cells.  The  amboceptor 
is  standardized  by  putting  in  each  of  a  series  of  test  tubes  1  c.c.  of 
complement  and  1  c.c.  of  5  per  cent  emulsion  of  sheep  red-cells.  Differ- 
ent amounts  of  the  inactivated  rabbit  serum  are  added  to  the  tubes,  be- 
ginning with  0.01  c.c.  to  0.1  c.c.  The  tubes  are  then  incubated  one  hour. 
That  in  which  complete  hemolysis  occurs  contains  just  enough  of  ambo- 
ceptor to  dissolve  1  c.c.  of  5  per  cent  emulsion  of  sheep  red-cells.  Double 
the  quantity  is  the  amboceptor  to  be  used.  Suspected  serum  to  be  used  is 
drawn  from  a  superficial  vein  with  a  medium-sized  exploratory  needle 
under  strict  aseptic  precautions,  about  5  c.c.  being  sufficient.  The  blood 
is  centrifuged  and  the  cleared  serum  inactivated  by  heat  for  thirty 
minutes  at  56°  C, 

Test. — Put  1  c.c,  of  complement,  2  drops  of  suspected  serum,  about 
0,1  c.c.  of  antigen  in  test  tube  and  incubate  one  hour  at  37°  C,  Then  add 
the  amount  of  amboceptor,  determined  by  standardization,  and  1  c.c, 
of  5  per  cent  emulsion  of  sheep 's  red-cells  suspended  in  normal  salt  solu- 
tion and  incubate  again  for  one  hour.  Then  place  in  ice  box  for  six 
hours.  Complete  hemolysis  is  indicated  by  a  clear  burgundy-red  solu- 
tion, showing  no  precipitate.  No  hemolysis  is  indicated  by  a  solid, 
opaque  sediment  of  the  unaflfected  sheep  cells  at  the  bottom  of  the  tube, 
while  the  supernatant  fluid  is  clear  and  colorless, 

Eesult:  Hemolysis,  no  syphilis;  syphilis,  no  hemolysis.  The  control 
test  is  the  same  except  that  the  antigen  is  omitted,  (After  G,  M.  Gould 
and  R.  J.  E.  Scott.) 

The  Noguchi  method  of  the  serum  diagnosis  of  syphilis  is  a  modifica- 
tion of  the  Wassermann  reaction,  ''(1)  He  prepares  the  antigen  by 
extracting  a  lipoid  substance  from  the  liver  and  heart  of  dogs  and  cows. 


86  DISEASES   OF    CHILDREN 

(2)  Instead  of  using  sheep's  corpuscles  in  the  hemolytic  series,  he  em- 
ploys human  corpuscles,  owing  to  the  fact  that  a  certain  percentage  of 
human  sera  tested  produced  hemolysis  of  the  sheep's  corpuscles.  (3) 
In  his  test,  therefore,  he  obtains  the  hemolytic  amboceptor  by  immuniz- 
ing rabbits  with  washed  normal  human  corpuslces.  (4)  Another  im- 
portant improvement  in  the  technic  is  the  preservation  of  the  specific 
antigen  and  the  hemolytic  amboceptor,  which  rapidly  lose  their  strength 
in  solution,  in  a  dried  form  by  soaking  measured  strips  of  filter-paper 
(.5  mm.  square)  with  each.  His  test  is  carried  out  as  follows:  A  strip 
of  antigen  filter-paper  is  brought  in  contact  with  a  definite  quantity  of 
the  human  serum  to  be  tested  and  fresh  guinea-pig's  serum  added,  the 
whole  being  suspended  in  isotonic  salt  solution.  This  is  allowed  to  stand 
at  incubator  temperature  and  then  the  hemolytic  series  added  by  taking 
a  strip  of  the  hemolytic  amboceptor  paper  and  a  definite  quantity  of 
washed  normal  human  blood  corpuscles." — (Tyson's  Practice  of  Medi- 
cine.) 

Senrni  Diagnosis  of  Typhoid 
(  Gruber-Widal  ) 

The  blood  of  persons  suffering  from  typhoid,  Avhen  added  to  a  broth 
culture  of  typhoid  bacilli,  arrests  the  characteristic  movements  of 
these    germs   and   produces   their   agglutination    and    sedimentation. 


Fig,  5. — Stages  in  Widal  reaction  of  typhoid   (after  Eobin). 

This  phenomenon  may  be  observed  macroscopically  in  a  suspension 
of  bacteria  in  test  tubes ;  or  microscopically  when  the  bacteria  are  mixed 
with  the  blood  and  mounted  in  a  hanging  drop  preparation.  The  test 
is  generally  positive  in  typhoid  patients  after  the  fifth  day  of  the  disease 
and  several  weeks  thereafter. 

The  blood  (or  serum  from  a  blister)  is  obtained  from  the  skin  cov- 
ering the  ear  lobe.    After  cleaning  this  part,  the  lobe  is  pricked  with 


PREVENTION    AND    CONTROL   OF   DISEASE  87 

a  sterile  needle,  and  two  drops  of  blood  are  placed  on  a  glass  slide,  one 
near  each  end,  and  allowed  to  dry  in  the  air.  The  examination  can 
then  be  undertaken  any  time  thereafter  by  diluting  one  drop  of  the 
blood  in  ten  or  twenty  parts  of  the  typhoid  culture. 

Weil-Felix  Reaction  of  Typhus  Fever 

What  is  known  as  the  Weil-Felix  reaction  has  recently  come  into 
use  abroad  in  the  diagnosis  of  typhus  fever,  and  as  its  value  has  seem- 
ingly been  proved,  it  should  be  employed  for  confirmation  of  clinical 
diagnosis  in  all  suspected  cases  of  typhus  or  continued  fever. 

This  reaction  is  similar  to  the  Widal  test  in  typhoid,  and  consists  in 
testing  the  agglutinating  power  of  the  patient's  blood  serum  on  a 
suspension  of  bacilli  obtained  from  cases  of  typhus  fever,  which  have 
tentatively  been  classed  as  various  members  of  the  Proteus  group  of 
organisms.  The  bacilli  in  question  were  described  by  Weil  and  Felix 
as  short  Gram-negative  rods,  slightly  motile,  forming  blue  colonies  on 
Conradi-Drigalski  medium,  and  colonies  which  become  pink  on  Endo 
medium.  The  organisms,  according  to  these  authorities,  ferment  dex- 
trose and  curdle  milk,  with  the  development  of  an  acid  reaction,  and 
liquefy  gelatin.    They  are  also  stated  to  produce  indol. 

The  technic  of  the  agglutination  test  (as  recommended  by  Weil 
and  Felix)  is  as  follows :  The  growth  of  the  proteus-like  bacillus  on 
an  agar-slant  is  suspended  in  a  small  quantity  (2  c.c.)  of  0.9  per  cent 
salt  solution,  and  this  is  mixed  in  the  proportions  of  1  to  25,  and  1  to 
50,  with  serum  from  the  suspected  case.  Hanging  drops  of  these 
dilutions  are  then  examined  microscopically  after  a  half  hour's  incu- 
bation at  37°  C. 

In  positive  cases,  agglutination  should  take  place  in  dilutions  of  1 
to  25,  on  the  6th  day;  and,  by  the  12th  day  of  the  disease,  in  dilutions 
of  as  great  as  1  to  200,  or  higher. 

Allergy-  or  Food  Idiosyncrasy-Test 

This  test  is  of  great  diagnostic  and  hence  therapeutic  value  in  de- 
termining food  idiosyncrasies  which  are  not  rarely  responsible  for 
marked  gastrointestinal  disturbances,  skin  affections  and  asthma. 

The  technic  is  the  same  as  in  von  Pirquet  tuberculin  test,  using  the 
soluble  food  product  instead  of  the  tuberculin. 

A  positive  reaction  is  manifested  in  from  ten  to  thirty  minutes  by 
the  appearance  of  a  blotchy  papular  eruption  about  i/^  inch  in  diameter, 
accompanied  by  local  or  general  itching  of  the  body.  This  may  be 
followed    by   asthmatic   breathing.     A   positive   reaction,    of   course, 


88  DISEASES   OF    CHILDREN 

calls  for  the  removal  of  that  particular  kind  of  food  from  the  dietary, 
until  the  susceptibility  has  disappeared. 

The  following  food-testing-products  are  marketed  by  the  Arlington 

Chemical  Company,  Yonkers,  N.  Y.,  or  Squibb  and  Sons,  New  York. 

Almond  Laetalbumin 

Banana  Lamb 

Barley  Lentil 

Bean  Lettuce 

Beef  Lobster 

Buckwheat  Oats 

Cabbage  Onion 

Carrot  Orange 

Casein  Oyster 

Clam  Pea 

Cocoa  Peanut 

Codfish  Pork 

Corn  Potato 

Crab  Eiee 

Cucumber  Eye 

Egg  Albumin  Squash 

English  Walnut  Strawberry 

Grapefruit  Tomato 

Haddock  Wheat 


IV.  MATERIA  MEDICA  AND  THERAPEUTICS 
(Including  Hydrotherapy,  Electricity,  Massage,  and  Climatotherapy) 

No  one  method  of  treatment  suits  all  cases.  Some  diseases  sub- 
side spontaneously,  if  let  alone;  others  go  from  bad  to  worse  if  not 
treated  promptly  and  energetically.  Some  affections  yield  readily 
to  biologic  remedies,  others  to  crude  drugs  or  synthetic  pharmaceuti- 
cal preparations,  and  again  others  respond  to  change  of  climate,  mode 
of  living  and  eating,  and  to  remedial  measures  other  than  pharma- 
ceutical, such  as  hydrotherapy,  massage,  electricity  and  the  like. 

Our  duty  being  to  alleviate  suffering,  we  owe  it  to  our  patients  to 
keep  pace  with  the  advances  of  the  time  and  to  employ  every  useful 
method  of  treatment  regardless  of  its  source  or  character.  "The  pe- 
riod of  exclusiveness  is  past."  While  a  certain  degree  of  conserva- 
tism is  always  wise  and  safe,  skepticism  to  well-tried  remedies  is 
worse  than  folly. 

Hydrotherapy 

The  virtue  of  water  as  a  therapeutic  agent  varies  with  the  idiosyn- 
crasy of  the  patient,  the  temperature  of  the  water  employed  and  the 
method  of  its  application. 

Heat  applied  to  the  surface  of  the  body  produces  a  relaxation  of  the 
vasomotor  system.     The  cutaneous  vessels  dilate  and  become  more  ac- 


PREVENTION   AND    CONTROL   OF   DISEASE  89 

tive,  diaphoresis  ensues,  and  effete  matter  is  eliminated.  The  volume 
of  blood  in  the  deeper  structures  is  diminished;  hence,  congestion  re- 
lieved. The  temperature  of  the  body  is  first  increased,  but  after  free 
diaphoresis  considerably  lowered. 

Cold  contracts  the  terminal  blood  vessels  and  stimulates  the  internal 
circulation.  It  reduces  the  temperature  of  the  body  not  only  by  con- 
duction but  also  by  inhibition  of  heat  production.  Soon  after  discon- 
tinuance of  the  cold  a  reaction  takes  place,  respiration  becomes  deep 
and  full,  more  carbon  dioxide  is  excreted  and  the  supply  of  oxygen 
is  increased.  The  pulse,  which  is  at  first  feeble,  soon  becomes  full  and 
strong;  the  chilliness  and  rigor  disappear,  and  a  sensation  of  warmth 
pervades  the  body  surface.  The  blood  current  in  the  capillaries  becomes 
gradually  accelerated  and  the  internal  circulation  relieved  of  its  tension. 

The  External  Use  of  Water. — ^Neither  extreme  heat  nor  extreme  cold 
should  be  employed  in  the  treatment  of  diseases  of  children.  Heat 
should  be  avoided  on  account  of  the  severe  depression,  and  cold  because 
of  the  shock  it  is  apt  to  produce. 

Cold  Sponging. — In  the  employment  of  cold  water  in  the  treatment 
of  diseases  of  children,  sponging  advantageously  supplants  the  cold 
bath.  The  temperature  of  the  water  should  vary  between  70°  and  90° 
F.  Three  basins  of  water,  one  each  of  70°  F.,  80°  F.  and  90°  F.,  respec- 
tively, are  placed  at  the  bedside.  The  child  is  stripped  and  laid  upon 
a  blanket,  and  by  means  of  cloths  the  surface  of  the  body  is  sponged 
for  from  two  to  three  minutes,  in  the  following  order  of  succession: 
face,  neck,  chest,  back,  abdomen,  buttocks,  upper  and  lower  extremities. 
The  warmest  water  (90°  F.)  is  used  first  and  the  coldest  (70°  F.)  last. 
Each  part  of  the  body  should  be  thoroughly  dried  immediately  after  it 
has  been  sponged.  The  indications  for  the  use  of  the  sponge  bath  are 
hyperpyrexia  and  nervous  irritability;  constitutional  disorders,  such  as 
anemia,  chlorosis,  scrofula,  etc.,  and  in  cases  in  which  a  general  tonic 
effect  is  desired.  In  the  latter  conditions  sponging  should  be  followed 
by  active  friction. 

Cold  Wet  Pack. — The  child  is  stripped  and  blankets  are  placed  over  and 
under  it.  A  small  sheet  is  dipped  in  water  at  a  temperature  of  70°  to  90° 
F.,  thoroughly  wrung  out  and  wrapped  loosely  around  the  patient.  The 
child's  body  is  then  enveloped  in  the  blankets.  To  reduce  high  tem- 
peratures, for  example,  in  typhoid  or  pneumonia,  ice  may  be  rubbed 
over  the  pack.  The  next  pack  is  applied  after  an  interval  of  ten  min- 
utes and  may  be  repeated  from  ten  to  twelve  times  in  twenty-four  hours. 
The  feet  should  be  kept  warm  by  artificial  heat. 

Vapor  Pack. — If  the  cold  wet  pack  is  allowed  to  remain  in  position  for 
from  one  to  two  hours  and  loss  of  body  heat  prevented  by  thoroughly 


00  DISEASES   OF    CHILDREN 

covering  the  child  with  woolen  blankets,  the  cold  pack  is  converted  into 
a  warm  pack  which  produces  effects  similar  to  those  obtained  from  a 
vapor  bath — namely,  free' diaphoresis,  lowered  activity  of  the  nervous 
system,  calm  and  repose,  and  equalization  of  the  internal  circulation. 
The  vapor  pack  is,  therefore,  invaluable  in  acute  catarrhal  conditions 
of  the  air  passages,  in  nephritis,  dropsical  effusions,  muscular  rheuma- 
tism, eclampsia,  hyperesthesias,  etc. 

Wet  Local  Compresses  (Priessnitz). — Cold  Compresses. — These  are  ap- 
plied in  all  forms  of  local  inflammation,  to  relieve  pain,  swelling,  heat 
and  redness.  In  order  to  obtain  good  results,  the  temperature  of  the 
water  should  vary  between  50°  and  60°  F.,  and  the  compress  left  in 
place  and  kept  cold  either  by  frequently  sprinkling  cold  water  over  it 
or  by  the  application  of  an  ice  bag. 

Indications:  Headache,  angina,  acute  pharyngitis  and  laryngitis, 
hemoptysis,  appendicitis,  intestinal  hemorrhage,  etc. 

Warm  Compresses. — ^While  cold  compresses  delay  the  flow  of  blood 
and  cell  activity,  warm  compresses  accelerate  the  blood-current  and 
promote  cell  activity.  They  are  applied  by  means  of  cloths  immersed 
in  water  at  a  temperature  of  about  100°  F.,  thoroughly  wrung  out, 
then  covered  with  flannel  and  rubber  tissue  or  oiled  silk  to  prevent  rapid 
evaporation  and  cooling.  The  compresses  should  be  changed  as  soon  as 
they  become  dry. 

Indications :  Neuralgia  of  the  head ;  throat  affections  after  subsidence 
of  the  acute  inflammatory  stage,  to  promote  absorption  of  diseased  prod- 
ucts; in  exudative  pleuritis;  in  bronchitis,  to  allay  severe  cough  and  to 
promote  expectoration;  in  all  spasmodic  conditions  of  the  intestines;  to 
hasten  suppuration  and  relieve  stasis. 

Baths. — Tepid  Bath. — This  is  a  very  useful  bath  in  children.  The 
temperature  of  the  tepid  bath  varies  between  85°  F.  and  92°  F.  It  is 
employed  in  diseased  conditions  requiring  soothing,  for  example,  in  erup- 
tive skin  diseases  and  as  an  antipyretic  in  infectious  diseases. 

Warm  Bath. — In  a  general  sense,  this  is  the  most  valuable  bath  in  the 
treatment  of  diseases  of  children.  It  tranquilizes  the  nervous  system, 
equalizes  the  circulation,  produces  diaphoresis  and  reduces  temperature. 

Indications:  All  spasmodic  conditions;  affections  of  the  lungs  and 
kidneys;  exanthematous  diseases,  and  nervous  affections,  such  as  hys- 
teria, etc.  The  temperature  of  the  bath  should  vary  between  92°  F. 
and  98°  F.  The  patient  should  remain  in  the  bath  for  from  two  to 
five  minutes.  The  warm  bath  is  sometimes  employed  as  a  permanent 
hath,  in  extensive  burns  and  wounds,  and  in  skin  diseases  associated 
with  intense  itching.    The  patient  is  suspended  in  the  bath  on  a  sheet. 


PREVENTION    AND    CONTROL    OF   DISEASE  91 

The  water  is  kept  at  an  equal  temperature  by  proper  arrangement  of 
inflow  and  outflow. 

Hot  Bath. — The  temperature  of  the  hot  bath  may  be  carried  gradually 
as  high  as  108°  F.,  and  the  patient  should  remain  in  the  bath  for 
from  one  to  three  minutes.  It  is  very  useful  in  collapse,  convulsions 
and  chronic  rheumatic  conditions.  It  is  occasionally  administered  to 
break  up  a  "cold,"  and  to  produce  rapid  diaphoresis.  While  in  the 
bath  the  patient's  head  should  be  kept  cool  by  an  ice  bag. 

Shower  Bath. — Cold  shower  baths  are  generally  given  for  their  stim- 
ulating effect.  Hence,  they  are  of  great  value  in  nervous  affections, 
such  as  neurasthenia ;  in  enuresis,  and  as  a  general  tonic.  For  these 
purposes  one  shower  (shock)  at  a  time  is  sufficient.  The  shower  bath 
should  be  followed  by  active  friction. 

Aspersion  Bath. — The  value  of  cold  water  dashed  suddenly  over  the 
frame  or  directed  in  a  steady,  broad  stream  upon  some  particular  part, 
is  very  great.  The  cases  in  which  such  a  mode  of  treatment  is  bene- 
ficial are  numerous.  The  following  are  a  few  of  the  more  important : 
Where  the  muscular  power  of  a  leg  or  arm  is  impaired  from  long  inaction, 
as  in  cases  of  fracture,  dislocation,  sprains  and  partial  paralysis.  The 
patient  sits  in  a  bath  tub  or  on  the  floor  and  the  operator,  standing 
on  a  table,  directs  the  stream  of  cold  water  upon  the  affected  part  from 
a  watering  can  from  which  the  sprinkler  has  been  removed.  This  mode 
of  treatment  is  rendered  particularly  serviceable  if  the  circulation  is 
quickly  restored  by  vigorous  dry  friction  for  several  minutes.  It  is  also 
efficacious  in  systemic  poisoning  from  drugs,  suffocation  from  noxious 
gases,  etc. 

Medicated  Baths. — Aside  from  the  natural  mineral  baths  obtained 
in  the  celebrated  spas,  which  will  be  discussed  later,  a  number  of  arti- 
ficial baths  are  commonly  used  in  the  treatment  of  diseases  of  infancy 
and  childhood.  The  efficacy  of  these  baths  is,  in  the  majority  of  in- 
stances, probably  due  to  the  effects  of  heat  or  cold  and  friction  employed 
with  the  nonmedicated  bath. 

Nauheim  Baths. — These  baths  are  used  chiefly  in  the  treatment  of 
chronic  heart  disease,  and  diverse  neuroses.  Where  natural  springs  are 
not  within  reach,  the  baths  may  be  prepared  by  the  addition  of  the 
following  ingredients  which  evolve  carbonic  acid  gas;  the  therapeutic 
action  depends  chiefly  upon  its  stimulating  effect  upon  the  skin. 

Sodium   Chloride 4  lbs. 

Sodium  Bicarbonate    V2    " 

Calcium  Chloride    4    " 

Hydrochloric  Acid   1    " 


92  DISEASES   OP    CHILDREN 

The  hydrochloric  acid  is  added  gradually  after  the  other  ingredients 
have  been  thoroughly  dissolved  in  the  bath.  The  baths  should  be  taken 
two  or  three  days  in  succession,  followed  by  a  respite  of  two  days. 

Aromatic  Bath. — About  six  ounces  each  of  chamomile  flowers,  calamus 
roots  and  peppermint  leaves  are  tied  up  in  a  muslin  bag  and  thrown  into 
a  warm  bath.  Aromatic  baths  are  recommended  in  marasmus,  infantile, 
spinal  and  other  forms  of  paralysis,  in  sclerema,  etc. 

Bran  Bath. — Two  or  three  pounds  of  wheat  bran  are  boiled  for  about 
an  hour  in  about  three  quarts  of  water.  The  decanted  liquid  is  added 
to  the  bath.  It  is  useful  in  intertrigo,  eczema,  pemphigus,  lichen, 
strophulus,  etc. 

Malt  Bath. — A  few  ounces  of  malt  extract  are  added  to  the  bath. 
Malt  baths  are  recommended  in  rachitis,  spasm  of  the  glottis,  and  in 
general  debility. 

Mercurial  Bath. — This  form  of  bath  is  employed  as  an  adjuvant  in 
the  treatment  of  syphilis.  It  is  usually  prepared  by  the  addition  of 
20  to  30  grains  of  calomel,  or  0.5  to  1.0  grams  (7  to  15  grains)  of  bi- 
chloride of  mercury. 

Mustard  Bath. — Two  or  3  ounces  of  mustard  are  dissolved  in  a  few 
pints  of  tepid  water  and  added  to  the  bath,  or  the  mustard  powder 
is  tied  up  in  a  bag  and  thrown  in  the  tub.  The  temperature  of  the  bath 
may  vary  between  100°  F.  to  106°  F.  It  may  be  administered  in  the 
form  of  a  sitz  bath  or  full  bath.  The  patient  should  remain  in  the  bath 
for  from  three  to  ten  minutes.  Mustard  baths  are  indicated  in  collapse, 
shock  or  heart  failure  from  any  cause,  in  sudden  congestion  of  the 
lungs  or  brain,  etc. 

Sea  Salt  Bath. — About  2  pounds  of  sea  salt  are  dissolved  in  the  bath 
of  4  or  5  gallons  of  water.  It  is  stimulating  in  its  effects,  and  useful 
in  rachitis,  various  forms  of  paralysis,  etc. 

Soap  Bath. — This  form  of  bath  is  employed  in  the  treatment  of  pru- 
rigo, lichen,  strophulus,  scabies,  etc.  It  is  prepared  by  the  addition  of 
from  3  to  6  ounces  of  soft  green  soap  to  5  gallons  of  water. 

Sulphur  Bath. — Half  to  one  ounce  of  potassium  sulphuret  should  be 
added  to  each  bath.  In  some  cases  the  addition  of  about  3  ounces  of 
animal  gelatin  is  of  advantage.  Sulphur  baths  are  deserving  of  rec- 
ommendation in  rheumatism,  eczema,  prurigo,  urticaria,  lead  poisoning, 
etc. 

The  Internal  Use  of  Water 

The  benefits  derived  from  the  internal  use  of  water  are  mani- 
fold, but  unfortunately  greatly  underestimated.  Water  taken  by 
the    mouth    in    moderate    quantities — large    amounts    weaken    diges- 


PREVENTION   AND    CONTROL   OF   DISEASE  93 

tion — cleanses  the  alimentary  canal,  stimulates  peristalsis  and  pro- 
duces diuresis  and  diaphoresis.  To  a  certain  extent  it  acts  also 
as  a  food.  In  acute  diseases  associated  with  anorexia  the  free 
use  of  water  will  often  sustain  life  for  weeks.  In  febrile  diseases 
water  not  only  quenches  thirst,  but  aids  also  in  the  reduction  of  tem- 
perature. Water  stimulates  expectoration,  and  in  the  form  of  cracked 
ice  checks  vomiting.  For  the  latter  purpose  small  sips  of  hot  water 
are  sometimes  resorted  to. 

Lavage. — Stomach  washing  in  children  is  performed  in  the  same  man- 
ner as  in  adults.  Its  field  of  usefulness,  however,  is  much  wider.  It  is 
invaluable  in  cases  of  acute,  simple  and  toxic  gastritis,  pyloric  stenosis, 
cholera  infantum,  chronic  indigestion  and  difficult  feeding.  A  funnel 
with  a  few  feet  of  rubber  tubing,  to  which  a  soft  rubber  catheter  (No. 
12  or  14)  is  joined  by  means  of  a  glass  cannula,  is  the  best  apparatus  for 
stomach  washing.  About  10  inches  of  the  catheter  should  be  passed  be- 
yond the  lips.  The  temperature  of  the  irrigating  solution  should  be 
about  100°  F.,  or  higher,  if  special  indications  arise.  The  quantity  of  so- 
lution to  be  instilled  varies  with  the  capacity  of  the  child's  stomach. 
Generally,  pure,  boiled  water  answers  all  medicinal  purposes,  except  in 
poisoning,  in  which  instance  antidotes  may  be  employed.  In  hyper- 
acidity of  the  stomach  bicarbonate  of  soda  or  lime  water  may  be  added. 
Lavage  is  contraindicated  in  heart  disease  and  hemorrhagic  diathesis. 

Irrigations. — The  action  of  irrigations  is  chiefly  mechanical.  They  are 
indispensable  in  the  treatment  of  divers  affections  of  the  lining  mem- 
branes of  internal  cavities.  In  chronic  cystitis,  for  example,  washing 
of  the  bladder  by  means  of  sterile  or  medicated  (boric  acid,  silver  ni- 
trate) water  will  often  rapidly  effect  a  cure. 

Irrigations  of  the  vagina  are  frequently  employed  in  vulvovaginitis. 
A  slow  current  of  water  should  be  employed,  permitting  the  fluid  to 
return  without  injury  to  the  adjacent  parts.  A  fountain  syringe  with 
a  small,  sterile,  soft  rubber  catheter  attached,  generally  suffices  for 
ordinary  purposes.  The  water  bag  should  be  suspended  about  2  feet 
above  the  child's  body. 

Irrigations  with  warm,  sterile  water  are  very  beneficial  in  ear  affec- 
tions, such  as  impacted  cerumen,  foreign  bodies  in  the  external  audi- 
tory meatus  and  in  otitis  media. 

In  febrile  diseases,  adenoids,  chronic  pharyngitis,  etc.,  instillations  of 
weak  salt  water  or  ichthyol  solutions  prevent  and  cure  affections  of  the 
nasopharynx  and  ear ;  it  often  also  relieves  reflex  cough  and  embarrassed 
respiration.  Instillation  may  be  performed  by  means  of  a  teaspoon  or 
dropper,  and  should  be  repeated  at  least  twice  a  day. 


94  DISEASES   OP    CHILDREN 

Copious  irrigations  of  the  mouth  with  sterile  or  medicated  (silver  ni- 
trate, hydrogen  peroxide)  water  are  invaluable  in  the  treatment  of 
grave  forms  of  stomatitis.  • 

E7iteroclysis. — The  indications  for  low  enemas  are  too  well  known  to 
need  further  discussion.  It  may  be  mentioned,  however,  that  in  habit- 
ual constipation  only  small  quantities  of  water  should  be  injected  into 
the  bowel.  Large  quantities  are  apt  to  produce  atony  of  the  colon  by 
overdistention  and  thus  aggravate  the  disease. 

High  enemas  are  given  by  means  of  a  flexible  (colon)  tube  and  a  foun- 
tain syringe.  High  enemas  not  only  remove  effete  material  from  the 
intestines,  but  by  using  water  at  a  temperature  of  80°  to  90°  F.  also 
reduce  temperature.  Hence,  they  combine  two  therapeutic  measures, 
which  are  of  signal  benefit  in  all  gastrointestinal  disorders,  peritonitis, 
typhoid,  etc.  Soap  suds,  bicarbonate  of  soda,  turpentine,  starch  and 
salt,  among  other  adjuvants,  may  be  added  according  to  indications. 

Saline  injections  stimulate  the  kidneys  and  promote  elimination  of 
putrid  material.  They  stimulate  the  circulation  and  supply  the 
deficiency  of  body  fluids  in  conditions  associated  with  an  excessive 
drain  of  fluids.  Saline  injections  are,  therefore,  a  sovereign  remedy  in 
uremia,  typhoid  fever,  scarlet  fever,  smallpox,  measles,  diphtheria, 
eclampsia,  anemia,  hemorrhages,  and  in  shock  after  surgical  operations, 
etc. 

A  physiologic  (0.9  per  cent)  salt  water  solution  at  a  temperature  of 
from  100°  to  110°  F.  is  generally  used.  It  should  be  injected  slowly 
through  a  colon  tube,  and  continued  for  from  fifteen  to  twenty  minutes, 
or  by  Murphy-drip  for  several  hours  in  succession. 

Saline  injections  are  contraindicated  in  chronic  kidney  disease,  the 
salt  acting  as  an  irritant. 

Hypodermoclysis. — Subcutaneous  injection  of  salt  water  (110°  F.)  is 
performed  by  means  of  an  ordinary  fountain  syringe  with  an  antitoxin 
syringe  needle  attached.  The  syringe  needle  and  skin  should  be  ren- 
dered aseptic.  The  injection  should  be  made  in  places  where  there  is 
an  abundance  of  subcutaneous  cellular  tissue ;  for  example,  the  anterior 
surface  of  the  abdomen  and  thorax.  The  current  should  be  very  slow, 
and  the  quantity  of  the  saline  solution  to  be  injected  should  vary  be- 
tween from  2  to  6  ounces,  according  to  age  and  indications.  Hypo- 
dermoclysis is  of  inestimable  value  in  cases  of  collapse  resulting  from 
hemorrhage;  in  pneumonia;  uremia;  acute  gastroenteritis  with  great 
loss  of  body  fluids ;  and  in  leukemia.  In  infants  it  should  be  preferred 
to  intravenous  infusion.  More  recently  good  results  have  been  reported 
from  intravenous  infusion  by  the  longitudinal  sinus  route  and  by  peri- 
toneal injection. 


PREVENTION    AND    CONTROL    OF    DISEASE  95 

hitrasinus  Injection. — In  an  infant  with  open  fontanel  this  offers  the 
best  means  of  introducing  fluid  into  the  blood  stream.  The  method  was 
first  studied  by  Tobler  and  was  introduced  in  this  country  only  a  few 
years  ago  by  Helmholz.  By  this  technic,  the  fluid  can  be  injected 
through  the  anterior  fontanel  directly  into  the  superior  longitudinal 
sinus.  As  the  sinus  lies  from  2  to  5  mm.  from  the  skin,  it  can  be 
easily  entered  if  the  fontanel  is  not  closed ;  at  the  posterior  angle  of  the 
fontanel  the  sinus  is  wider  and  deeper.  The  child  is  held  prone  on  the 
table  by  an  assistant,  while  the  needle  is  introduced  in  the  median  line 
just  in  front  of  the  posterior  angle.  If  the  child  is  quiet,  it  is  verj^  easy 
to  withdraw  blood  or  to  introduce  fluid;  by  means  of  a  Luer  syringe, 
rubber  tubing  and  a  threeway  cock  any  amount  of  fluid  can  be  given 
without  removing  the  syringe.  The  needle  should  be  short,  and  the  long 
point  usually  found  on  intravenous  needles  should  be  filed  away.  If  a 
glass  syringe  is  attached  before  introduction  of  the  needle,  constant 
suction  may  be  maintained  for  the  purpose  of  discerning  when  the  sinus 
is  entered.  If  negative  pressure  is  not  produced,  blood  will  not  flow  so 
quickly,  while  the  operator  may  push  the  needle  through  the  inferior 
wall  of  the  sinus,  blood  flowing  only  when  the  needle  is  withdrawn.  This 
accident  may  also  be  avoided  if  the  needle  be  introduced  at  an  angle, 
directed  backward. 

Any  solution  adapted  to  intravenous  administration  can  be  given  in 
this  way;  with  physiologic  sodium  chlorid,  glucose  and  other  mild  solu- 
tions there  is  practically  no  danger.  It  is  also  an  excellent  method  for 
transfusion  of  citrated  whole  blood  in  infants. 

In  eases  with  a  closed  fontanel,  the  external  jugular  or  femoral  vein 
can  often  be  used  successfully. 

Intraperitoneal  Injection. — This  was  first  used  in  St.  Bartholomew's 
Hospital  and  was  introduced  in  this  country  by  Howland.  As  may  be 
noted  from  the  following  observations  of  J.  Aikman  (Rochester,  N.  Y.)* 
its  method  of  application  is  very  simple. 

The  instruments  needed  are  a  medium-sized  intravenous  needle,  an 
infusion  bottle  and  rubber  tubing.  The  skin  of  the  abdomen  is  carefully 
sterilized  with  tincture  of  ipdin  and  alcohol.  The  skin  and  subcutaneous 
tissue  are  picked  up  between  the  thumb  and  forefinger,  and  the  needle 
is  introduced  in  an  upward  direction  through  the  abdominal  wall  in 
the  midline  just  below  the  umbilicus.  Care  must  be  taken  to  avoid  pierc- 
ing a  distended  bladder,  and  while  there  is  also  danger  of  puncturing 
the  intestine,  no  record  of  this  accident  has  come  to  his  attention.  In 
cases  in  which  necropsy  was  performed  there  was  found  a  small  hemor- 


•CJour.  Am.  Med.  Assn.,  Ixxiv,  No.  4,   1920.) 


96  DISEASES   OF    CHILDREN 

rhagic  area  in  the  abdominal  wall  and  peritoneum,  but  no  injury  of 
serious  importance. 

When  the  needle  has  passed  into  the  peritoneal  cavity,  the  solution 
is  introduced  by  gravity.  At  first  he  used  a  Luer  syringe ;  but  later  he 
found  it  much  easier  to  employ  the  infusion  bottle.  He  has  always  used 
warm  physiologic  sodium  chlorid  solution,  of  which  from  100  to  250  c.c, 
in  older  children  from  300  to  400  c.c,  may  be  given  every  twelve  to 
twenty-four  hours,  in  fact,  if  no  untoward  signs  develop,  fluid  may  be 
given  until  the  abdomen  becomes  slightly  distended.  However,  the  in- 
jection must  be  made  slowly  in  all  cases,  and  overdistention  of  the  ab- 
domen must  be  avoided.  After  the  operation,  the  abdomen  is  covered 
with  a  sterile  dressing.  It  has  been  shown  by  the  phenolsulphonephtha- 
lein  test  and  by  necropsy  that  from  40  to  60  per  cent  of  the  fluid  is  ab- 
sorbed in  one  hour.  The  remaining  solution  acts  as  a  reserve,  the  gradual 
absorption  of  which  explains  the  more  protracted  improvement  as  com- 
pared to  results  obtained  by  other  methods. 

He  had  used  the  other  methods  at  the  Infants  Summer  Hospital,  but 
this  year  he  chose  the  intraperitoneal  route  for  children  who  had  lost 
large  amounts  of  fluid  by  vomiting  and  diarrhea.  It  proved  superior  to 
all  other  methods  because  of  the  ease  and  rapidity  of  administration,  the 
volume  of  fluid  that  can  be  given  at  one  time,  and  the  certainty  that  no 
fluid  will  be  lost.  The  results  from  this  treatment  are  remarkable ;  and 
although  it  has  been  used  only  in  the  most  serious  cases,  the  results  have 
been  most  satisfactory. 

The  fluid  carried  the  child  over  the  critical  days  until  the  bowel  con- 
dition began  to  improve.  He  had  never  before  seen  a  child  recover  as 
quickly  after  so  long  and  severe  an  illness.  The  recovery  is  evidence  of 
the  value  of  this  method  of  treatment  and  of  the  safety  with  which  re- 
peated injections  may  be  made  through  the  abdominal  wall. 

Electricity 

Electricity  as  a  remedial  agent  in  the  treatment  of  diseases  of  chil- 
dren is  employed  in  the  following  forms,  in  order  in  which  they  are 
named:     Galvanic,  faradic  and  static. 

The  Galvanic  Current. — The  effect  of  the  galvanic  or  direct  current  on 
the  muscle  is  to  produce  contraction.  The  contraction  takes  place  at 
the  moment  the  current  is  closed  or  opened  (make  or  break).  The  gal- 
vanic current,  if  applied  by  means  of  two  electrodes  along  the  course  of 
a  motor  nerve,  produces  a  uniform  contraction  of  the  entire  muscle  sup- 
plied by  that  nerve.  The  reaction  produced  by  the  constant  current  upon 
the  sensory  nerve  varies  according  as  the  application  is  made  with  the 
positive  or  negative  electrode,  the  anode  being  sedative  in  its  effects,  the 


PREVENTION    AND    CONTROL   OP    DISEASE  97 

cathode  stimulating.  A  constant  current  of  suitable  strength — 10  to 
15  milliamperes — passed  through  living  tissues  causes,  at  the  point  of 
contact  of  the  anode,  an  accumulation  of  oxygen,  chlorine  and  acid; 
coagulation  and  shrinking  of  the  exposed  tissue — positive  electrolysis. 
On  the  other  hand,  if  the  cathode  is  brought  in  contact  with  living  ani- 
mal tissue,  hydrogen  and  the  alkalies  are  set  free,  and  liquefaction  of 
the  parts  adjacent  to  the  electrode  takes  place — negative  electrolysis. 

The  Faradic  Current. — The  faradie  or  induced  current  causes  contrac- 
tion of  muscles  and  nerves  and  is  very  effective  in  producing  muscular 
massage.  It  stimulates  nerve  action  and  nutrition,  excites  secretion, 
and  arouses  latent  physiologic  function. 

The  Static  Current. — The  static  current  produces  vivid  and  persistent 
contraction  of  a  .large  group  of  muscles  with  a  minimum  of  pain.  The 
second  prominent  characteristic  of  this  current  is  its  power  of  relieving 
pain.    The  same  applies  to  the  ultra  violet  rays. 

The  following  rules  should  be  borne  in  mind  : 

1.  Alwaj's  administer  the  weakest  possible  current  that  will  cause  mus- 
cular contraction. 

2.  Never  employ  electricity  in  the  inflammatory  stage  of  organic  dis- 
ease. 

3.  In  applying  electricity  to  muscles  always  endeavor  to  reach  sepa- 
rately the  electromotor  points.  In  deep-seated  muscles  the  current 
should  be  applied  along  the  course  of  the  nerves  supplying  them. 

4.  Each  electric  treatment  should  last  no  longer  than  twenty  minutes, 
and  no  one  muscle  should  be  subjected  to  the  currents  for  more  than 
three  minutes. 

The  indications  for  electricity  in  the  treatment  of  diseases  of  children 
are  practically  the  same  as  in  adults.  The  discussion  of  the  subject 
will,  therefore,  be  limited  to  diseases  in  which  electricity  is  of  un- 
doubted value. 

Chronic  Constipation. — The  galvanic  or  faradic  current  maj-  be  used. 
One  electrode  is  passed  successi\  ely  over  different  portions  of  the  abdom- 
inal wall,  and  the  other  electrode  is  placed  upon  anj^  other  part  of  the 
body.     The  electric  treatment  should  be  continued  for  a  long  period. 

Diphtheritic  Paralysis. — In  this  condition,  faradization  of  the  respira- 
tory muscles,  particularly  of  the  diaphragm,  is  of  some  service.  It 
should  be  used  in  attacks  of  respiratory  failure  and  continued  while 
they  last. 

Enuresis. — The  broad  anode  is  placed  over  the  lumbar  region  of  the 
spine  and  the  small  cathode  over  the  region  of  the  bladder  or  upon  the 
perineum,  allowing  quite  a  strong  galvanic  current  to  act  for  from  two 
to  four  minutes.     Sometimes  faradization  proves  effective.     The  wire 


98  DISEASES   OF    CHILDREN 

end  of  the  conducting  cord,  connected  with  the  negative  pole,  should 
be  introduced  into  the  urethral  orifice  for  from  1  to  2  cm.  and  quite 
a  strong  faradic  current  allowed  to  act  for  from  one  to  two  minutes. 

Facial  Paralysis. — This  form  of  paralysis  is  greatly  benefited  by  a 
weak  stabile  galvanic  current.  It  should  be  employed  four  to  six  times 
a  week,  for  from  two  to  three  minutes  at  a  time.  The  anode  should  be 
placed  in  the  auricular  fossa  and  the  cathode  placed  behind  the  ear 
while  the  different  nerve  branches  and  the  muscles  are  slowly  stroked 
with  the  cathode.     In  later  stages  faradization  also  is  of  service. 

Hysteria. — The  vague  disconnected  symptoms  of  hysteria  call  for  gen- 
eral electric  treatment,  and  no  form  of  electricity  so  advantageously  com- 
bines tonic  and  sedative  effects  as  the  static  current.  A  mild  current 
should  be  employed.  Two  or  three  treatments  a  week  will  generally 
suffice.  Galvanism  and  faradism  also  are  of  service,  especially  in  hysteri- 
cal contractures. 

Multiple  Neuritis. — The  application  of  electricity  to  the  aft'ected  mus- 
cles is  important  in  order  to  maintain  their  nutrition.  It  should  be 
begun  after  the  acute  stage  has  passed,  that  is,  at  the  end  of  from  three 
to  four  weeks.  A  moderate  faradic  current  may  be  used  if  the  muscles 
respond  to  it;  otherwise  a  voltaic.  The  electricity  should  be  applied 
daily  by  means  of  large  electrodes,  so  that  the  current  may  reach  as 
much  muscular  tissue  as  possible.  The  current  should  be  strong  enough 
to  produce  visible  contraction  of  the  muscles. 

Poliomyelitis. — The  galvanic  current  gives  the  best  results.  It  should 
not  be  employed  earlier  than  the  third  or  fourth  week.  A  large,  flat 
electrode,  well  moistened  in  salt  water,  is  placed  upon  the  spine  over 
the  affected  region  and  the  muscles  were  repeatedly  stroked  by  means  of 
a  small  electrode.  The  current  should  be  of  such  strength  as  will  produce 
visible  contraction  of  the  muscles,  without,  however,  causing  severe 
pain  to  distress  the  child. 

Rheumatism. — The  sequelae  of  rheumatism,  atrophy  and  contractures 
often  call  for  electric  treatment.  The  galvanic,  faradic  or  static  cur- 
rent may  be  employed.  It  is  sometimes  advantageous  to  use  the  gal- 
vanic and  faradic  currents  at  one  sitting.  The  treatment  should  be 
repeated  at  least  every  alternate  day  and  continued  for  several  months. 
In  muscular  contracture  the  anode  should  be  placed  over  the  portion 
of  the  spine  governing  the  contracted  muscles  and  the  cathode  over 
the  muscles  themselves.  For  the  relief  of  pain  the  positive  pole  should 
be  applied  to  the  most  painful  spot. 

Tetany. — Electric  treatment  has  been  followed  by  improvement  in  a 
number  of  cases.     The  stabile  galvanic  current  should  be  employed; 


PREVENTION   AND    CONTROL   OF   DISEASE  99 

the  negative  pole  to  the  spine  and  the  positive  to  the  irritable  nerve 
trunks. 

Torticollis. — ^A  weak  galvanic  current  is  frequently  very  serviceable. 
The  positive  pole  should  be  placed  just  below  the  occiput  and  the  nega- 
tive pole  allowed  to  act  upon  the  contracted  muscles  for  from  five  to 
ten  minutes. 

The  indications  for  electrolysis  are  identical  with  those  in  adults. 

Massag-e 

Massage  is  a  mechanical  form  of  treatment  consisting  of  intelligent 
manipulations  of  the  superficial  parts  of  the  body.  It  is  intended  to 
produce  changes  in  the  local  and  general  nutrition,  action  and  other 
functions  of  the  body. 

Indications. — Massage  is  indicated  in  hysterical,  paralytic,  rheumatic 
and  traumatic  contractures  of  joints;  in  fractures,  to  hasten  absorption 
of  callous  masses;  in  chronic  glandular  enlargements;  in  swellings  asso- 
ciated with  rheumatism,  sprains,  contusion,  etc. ;  in  torticollis,  to  relax 
muscular  contraction ;  in  constipation,  atonic  dyspepsia  and  gastric  di- 
lation; in  all  forms  of  muscular  atrophy  or  dystrophy;  as  a  general 
stimulant  in  cases  of  prolonged  muscular  inactivity,  whether  from  in- 
dolence, disease,  feebleness  (rachitis)  or  prolonged  use  of  splints  or 
braces,  or  other  cause ;  in  various  forms  of  paralysis,  to  improve  the  nu- 
trition and  function  of  the  affected  muscles. 

Contraindications. — Massage  is  contraindicated  in  children  suffering 
from  gonorrheal  rheumatism  or  peliosis  rheumatica;  in  tuberculous,  ty- 
phoid or  syphilitic  ulcerations  of  the  intestines ;  in  acute  peritonitis,  ap- 
pendicitis, gastroenteritis,  gastric  ulcer;  in  tubercular  glandular  en- 
largements. 

Massage  generally  includes  the  following   principal  manipulations: 

Effleiirage  or  Stroking. — In  making  the  strokes  both  hands  are  em- 
ployed. The  limb  is  grasped  with  one  hand  just  above  the  other,  in 
such  a  manner  that  pressure  is  exerted  to  some  extent  by  the  whole 
palm,  but  especially  the  ball  of  the  thumb  and  the  inner  surface  of  the 
last  two  phalanges  of  the  fingers.  The  strokes  are  delivered  in  the 
form  of  an  ascending  spiral,  the  two  hands  being  moved  simultaneously 
in  opposite  directions,  the  lower  following  closely  upon  the  upper.  The 
strokes  must  be  made  with  great  regularity.  Light  stroking  has  a 
soothing  influence;  heavy  stroking  stimulates  the  superficial  structures, 
increasing  the  arterial,  venous  and  lymphatic  circulation. 

Friction. — This  manipulation  is  performed  with  the  fingertips  and 
consists  of  firm  circular,  semicircular,  or  to  and  fro  movements.     It  is 


100  DISEASES    OF    CHILDREN 

usually  combined  with  effleurage  and  is  intondod  to  promote  absorption 
by  the  veins  and  lymphatics. 

Petrissage  or  Kneading  and  Pinching. — In  kneading  the  endeavor  of 
the  operator  is  to  pick  up  the  individual  muscle  or  muscle  groups  be- 
tween the  fingers  of  the  two  hands,  or  in  some  cases  between  the  thumb 
and  finger  of  one  hand,  and  then  to  roll  and  squeeze  the  muscle  with  a 
double  movement.  These  manipulations  cause  circulatory,  nutritive 
and  alterative  changes  in  the  muscles,  tendons  and  organs  within  reach. 

Tapotement,  Percussion  or  Tapping. — Percussion  is  made  either  with 
the  points  of  the  fingers  brought  into  a  line  with  one  another  or  with 
the  side  of  the  hand  and  fingers.  The  movement  should  be  very  rapid 
and  elastic.  These  manipulations  are  usually  employed  on  muscular 
parts,  such  as  the  back  of  legs  and  gluteal  regions.  The  effect  of  tapote- 
ment is  similar  to  that  obtained  by  petrissage.  This  manipulation  may 
be  enforced  also  by  vibrations,  that  is,  by  rhythmic,  tremulous  movements 
under  pressure. 

Generally,  all  the  movements  are  practiced  at  one  sitting :  thus,  effleur- 
age, friction,  petrissage,  tapotement  and  vibration.  The  treatment  is 
concluded  by  effleurage.  While  in  local  affections  local  massage  is  gen- 
erally sufficient  to  effect  the  desired  results,  it  is  always  advantageous 
to  supplement  the  local  treatment  by  general  massage.  The  duration 
of  each  seance  varies  from  a  few  minutes  to  a  quarter  of  an  hour.  At 
first  the  treatment  should  not  last  more  than  five  minutes.  No  force 
should  be  used,  and  the  delicate  skin  of  the  child  should  be  spared  un- 
necessary injury.  It  is,  therefore,  advisable  to  anoint  the  skin  with 
boric  acid  vaseline,  cocoanut  oil  or  any  other  emollient.  In  young 
infants  massage  should  be  limited  to  general  friction  of  the  body.  In 
cases  of  malnutrition  it  is  a  good  rule  to  give  a  fat  inunction  daily 
after  the  morning  bath, 

Climatotherapy 

Change  of  climate  has  from  time  immemorial  been  recognized  as  a 
therapeutic  measure  par  excellence,  and,  fortunately,  our  great  country 
abounds  with  vast  mountain,  seashore  and  inland  resorts,  which  rival, 
if  not  surpass,  the  most  celebrated  spas  of  Europe. 

In  selecting  a  suitable  health  resort,  we  should  bear  in  mind  not 
only  the  state  of  health  and  the  peculiarities  of  the  individual  pa- 
tient, but  also  the  local  conditions  of  the  particular  resort,  such  as 
the  drainage,  water  supply,  prevalence  of  epidemic  or  endemic  dis- 
eases, etc. 

The  air  of  mountainous  regions  is  rarefied,  dry,  cool,  bracing  and 
free  from  organic  and  inorganic  impurities.     It  improves  the  action 


PREVENTION    AND    CONTROL   OF    DISlvASE  101 

of  the  skin;  favors  deeper  expansion  af  the  lungs,  and  correspondingly 
accelerates  the  heart's  action,  improves  sleep  and  stimulates  the  appe- 
tite and  the  powers  of  assimilation.  Mountain  air,  therefore,  is  par- 
ticularly beneficial  in  chronic  disorders  of  the  alimentary  tract  and 
liver;  in  anemia;  in  divers  respiratory  affections;  in  malaria;  in  rheu- 
matism, and  compensating  heart  disease. 

The  climate  of  the  seashore  is  pure  and  very  strong.  The  air  is 
loaded  with  moisture,  and  comparatively  free  from  dust  particles, 
hence  very  beneficial  to  convalescents  from  pneumonia,  pleurisy  and 
emp3'ema;  also  typhoid  and  surgical  operations.  It  often  acts  almost 
specifically  in  acute  gastroenteritis  of  infants. 

The  surf  baths  are  invaluable  in  cases  of  nervousness,  rachitis  and 
local  tuberculosis. 

Dry,  sheltered  inland  resorts  are  to  be  preferred  for  patients  suffer- 
ing from  noncompensating  heart  disease,  severe  bronchitis,  chronic 
kidney  disease,  and  all  such  affections  as  are  apt  to  be  badly  influenced 
by  sudden  variations  of  temperature. 

It  is  often  of  advantage  to  spend  part  of  the  summer  months  at  the 
seashore  and  part  time  in  the  mountains  or  inland  resorts.  Young 
children  suffering  from  tuberculosis  will,  during  the  winter  months, 
derive  the  greatest  benefit  from  a  sojourn  in  New  Mexico  and  Arizona. 
Children  over  ten  years  old  often  do  well  in  colder  climates,  such  as 
the  Adirondacks. 

Select  Medication  in  Children 

In  the  practice  of  medicine,  in  contradistinction  to  surgery,  every 
physician,  I  believe,  passes  through  three  well-defined  psychologic 
experiences  in  the  first  few  years  of  his  momentous  career.  Over- 
whelmed by  the  enthusiasm  over  the  infallibility  of  drugs  as  im- 
pressed upon  him  during  his  college  days  by  the  learned  professor  of 
materia  medica,  he  enters  the  medical  arena  with  boundless  confi- 
dence in  his  power  to  cope  with  every  phase  of  disease  and  anxiously 
awaits  the  opportunity  to  demonstrate  and  reap  the  benefit  of  his 
skill.  In  the  early  period  of  his  career  he  may  luckily  find  encourage- 
ment for  his  belief  and  anticipations,  rarely,  if  at  all,  surmising  that 
many  of  the  cures  he  happened  to  effect  were  in  reality  only  natural 
or  accidental  events,  often  based  upon  false  premises,  erroneous  diag- 
noses. Lo  and  behold !  A  few  unexpected  failures — and  his  fantastic 
dream  is  cruelly  shattered. 

With  multiplying  failures  the  state  of  exultation  is  gradually  re- 
placed by  that  of  depression,  his  hyperoptimism  changes  into  hyperpes- 
simism.     His  growing  skepticism  in  the  efficiency  of  medicines  often 


102  r^  jj,    \  S"^  l\  )'\  G  \  -'  DISEASES   OF   CHILDREN 

itebidfeiiiAi  io  ^eek  unalloyed  self  ^sufficiency  in  one  of  the  many  fields 
of  ^urgr»ry.  Or,  if  he  is  over  susceptible  to  the  pricking  of  his  con- 
science, he  even  goes  so  far  as  to  abandon  his  profession  entirely, 
little  realizing  that  no  profession,  trade  or  business  has  attained  the 
millennium  of  righteousness  and  immaculate  dealing  with  his  fellow- 
men.  Some  physicians,  although  continuing  to  practice  medicine  per- 
manently, float  in  the  "river  of  doubt,"  prescribe  nostrums  and  place- 
bos, or  fall  into  the  trap  of  the  polished  patent  medicine  mercenary  or 
promoter  of  some  newly  discovered,  but  invariably  threadbare,  mechani- 
cal device  or  manipulation,  or  spiritual  panacea,  cult  or  science. 

Fortunately,  most  of  us  are  not  so  readily  swayed  from  the  straight 
path  of  duty  by  such  melancholy  philosophy.  On  the  contrary,  we 
continue  conscientiously  to  minister  to  the  sick  and  to  strive  to  perfect 
our  knowledge  in  accord  with  the  scientific  advances  of  modern  medi- 
cine. Indeed,  as  wuth  many  years  of  hard  work  and  careful  study 
our  powers  of  intuition  and  judgment  improve  and  we  acquire  a  higher 
degree  of  skill  to  select  the  most  appropriate  remedial  measures  to 
combat  disease,  we  soon  find  ourselves  in  the  happy  psychic  state 
of  equanimity  and  self-reliance  and  content  with  our  noble  mission, 
undaunted  by  occasional  failures  and  untainted  by  triumph,  fully 
conscious  of  the  limitations  of  medicine,  yet  perfectly  confident  in  our 
ability  to  relieve  suffering,  to  prevent  disease  and  to  prolong  life. 

Those  of  us  who  believe  in  the  therapeutic  value  of  the  drugs  they 
prescribe,  must  first  of  all  see  to  it  that  their  patients  are  able  to 
swallow  and  retain  them.  As  a  rule,  adults  manage  by  means  of  cap- 
sules or  condiments  to  render  medicines,  disgusting  in  taste,  either 
tasteless  or  at  least  acceptable.  On  the  other  hand,  children  are  com- 
pelled to  take  the  medicine  as  given  to  them,  and  what  is  still  worse, 
the  more  they  resist,  the  more  they  are  subjected  to  anguish  and  dis- 
tress, na}^,  even  to  severe  corporal  punishment,  which  not  rarely 
borders  on  serious  injury. 

Indeed,  it  is  not  at  all  rare  to  find  little  children  suffering  from 
acute  lung  or  heart  disease  in  a  state  nigh  to  suffocation  from  the 
effects  of  prolonged  and  firm  compression  of  the  nostrils,  and  many  a 
helpless  child  bleeds  from  the  lips  and  gums  and  even  loses  a  tooth  or 
two  in  the  struggle  with  the  overzealous  mother  who  is  determined 
to  force  down  its  throat  a  teaspoonful  of  a  miserable  decoction,  which 
was,  perhaps,  intended  only  as  a  placebo.  There  is  certainly  no  excuse  for 
such  cruelty,  much  less  so  in  the  present  state  of  pharmaceutical  progress, 
which  enables  us  to  select  and  to  administer  the  most  potent  drugs  in 
concentrated  and  palatable  form. 


PREVENTION   AND    CONTROL   OF   DISEASE  103 

For  the  sake  of  convenience,  and  in  order  to  avoid  unnecessary  rep- 
etition, the  usual  classification  of  drugs  in  accord  with  their  therapeu- 
tic action  will  here  be  followed. 

Digestants 

Except  in  combination  with  other  drugs  digestants  are  rarely 
needed  in  the  treatment  of  diseases  of  children.  Occasionally  pan- 
creatin  is  indicated  in  starch  indigestion  of  infants,  and  may  be  pre- 
scribed either  in  powder  form  with  bicarbonate  of  soda  or  the  diasta- 
tic  essence,  with  or  without  a  small  quantity  of  milk  of  magnesia.  The 
latter  combination  mixed  with  glycerine  and  fennel-seed  water  will 
be  found  useful  in  colic.  The  elixir  digestivum  compositum  (N.F.) 
serves  as  a  very  palatable  vehicle. 

Tonics 

The  simple  bitters  fully  deserve  their  striking  cognomen,  since  they 
are  surely  very  bitter  and  simple,  insignificant,  in  therapeutic  action. 
I  believe  that  the  tincture  of  gentian,  quassia,  calumba  and  even 
cinchona  owe  their  trifling  medicinal  quality  to  the  alcohol  they 
contain.  Their  use  in  children,  therefore,  is  hardly  to  be  commended. 
Whenever  a  bitter  tonic  is  desired,  we  should  preferably  resort  to  a 
minute  dose  of  nux  vomica. 

Of  the  so-called  aromatic  bitters,  eucalyptol  is  the  only  preparation 
worth  mentioning.  Internally  it  may  be  administered  in  one  or  two 
drop  doses,  thoroughly  mixed  with  honey,  glycerine  and  mucilage, 
in  case  of  spasmodic  asthma  or  laryngitis,  and  in  the  same  affections 
it  is  very  useful  as  an  inhalation,  especially  if  combined  with  the 
compound  tincture  of  benzoin. 

Quinine,  which  is  erroneously  classed  among  the  peculiar  bitters,  is, 
of  course,  indispensable  in  the  practice  of  medicine.  Owing  to  its 
miserable  taste,  it  is,  unfortunately,  not  receiving  as  wide  an  applica- 
tion as  it  fully  merits.  We  are  all  familiar  with  its  specific  action  in 
malaria,  but  it  is  also  a  sovereign  remedy  in  pertussis,  pneumonia  with 
delayed  resolution,  and  in  irregular  or  chronic  grip.  I  am  not  pre- 
pared to  say  whether  or  not  the  brilliant  effect  in  these  cases  is  possi- 
bly due  to  some  latent  malarial  disposition.  Its  miserable  taste,  as 
already  stated,  often  precludes  its  administration  to  young  children, 
for  disguise  it  as  one  may,  quinine  will  always  taste  after  quinine 
as  long  as  there  is  quinine  in  the  mixture.  Some  time  ago*  I  suggested 
the  rectal  administration  of  bisulphate  of  quinine,  but,  while  this 
method  works  exceedingly  well  in  hospital  practice,  it  is  not  very 

*N.  Y.  Med.  Jour.,  Oct.  23,  1897. 


104  DISEASES   OF    CHILDREN 

ideal  as  a  routine  procedure.  Where  prompt  results  are  desired  we  do 
best  by  giving  it  by  mouth.  The  bisulphate  is  dissolved  in  water  and 
rendered  at  least  acceptable  by  the  addition  of  extractum  glycyrrhizae 
and  syrupus  acacias.  In  severe  cases  of  malarial  fever  characterized 
by  excessive  vomiting  and  pronounced  nervous  symptoms,  we  have 
to  resort  to  the  hypodermic.  Five  grains  of  quinine  hydrochloride 
dissolved  in  15  drops  of  hot  water  forms  a  suitable  dose  and  may  be 
injected  intramuscularly  under  most  careful  aseptic  precautions,  two 
or  three  times  daily.  In  pertussis  quinine  bisulphate  may  be  given 
in  one  or  two  grain  doses  every  two  to  four  hours,  whereas  one  or 
two  large  doses,  of  quinine  often  suffice  to  hasten  resolution  in 
pneumonia  or  grip.  Children  over  five  years  of  age  can  often  be  in- 
duced to  swallow  chocolate  coated  tablets. 

Of  the  numerous  iron  preparations  in  the  pharmacopeia  preference 
should  be  given  to  the  tincture  of  chloride  of  iron,  the  solution  of 
peptomanganate  of  iron,  the  syrup  iodide  of  iron,  and  the  dried 
sulphate.  Iron  is  always  useful  for  children  and  especially  for  infants 
fed  exclusively  on  milk,  which,  as  is  known,  is  poor  in  iron,  and  the 
solution  of  peptomanganate  of  iron  will  be  found  to  act  exceedingly 
well  in  all  simple  anemias  of  infancy.  The  tincture  chloride  of  iron 
is  usually  prescribed  as  a  styptic  and  hematinic  in  tonsillar  affections 
and  is  advantageously  administered  in  one  or  two  drop  doses  in  com- 
bination with  the  tincture  of  myrrh,  potassium  chlorate  and  glycerine. 
This  mixture  adheres  more  or  less  closely  to  the  tonsils  and  thus  exerts 
its  astringent  effect  upon  them,  often  dispensing  with  gargles  and  local 
applications.  The  syrup  iodide  of  iron  is  an  ideal  hematinic  tonic  in 
children,  more  especially  in  secondary  anemias  following  or  complicat- 
ing acute  infectious  diseases,  rachitis  and  diverse  forms  of  glandular 
enlargement.  In  the  so-called  scrofular  affections  it  often  acts  almost 
specifically,  more  particularly  if  combined  with  codliver  oil.  We  have 
ample  reason  to  believe  also  that  this  preparation,  in  addition  to  local 
attention  to  the  nasopharynx,  is  frequently  instrumental  in  reducing  or 
even  entirely  removing  adenoid  vegetations,  and  its  administration 
may  be  highly  recommended  to  children  who,  notwithstanding  the 
operative  removal  of  the  adenoids,  continue  to  suffer  from  persist- 
ent catarrh  of  the  respiratory  tract,  and  show  a  marked  disposition 
to  repeated  recurrence  of  the  adenoids.  Finally,  it  is  worth  empha- 
sizing that  owing  to  the  destructive  effect  of  liquid  iron  upon  chil- 
dren's teeth,  powdered  iron  with  a  little  sugar  or  in  tablet  form  should 
be  given  instead,  whenever  possible. 

The  selection  of  a  stable  and  palpable  phosphorous  preparation 
is  quite  a  problem;  hence  its  use  in  children  is  usually  limited  to  its 


PREVENTION    AND    CONTROL    OF    DISEASE  lOo 

derivatives.  The  syrup  of  lime  and  soda  hypophosphites  will  be  found 
particularly  beneficial  in  rachitis  and  associated  affections,  such  as 
tetany  and  eclampsia  infantum.  It  may  advantageously  be  combined 
with  syrup  iodide  of  iron  and  codliver  oil,  which  contrary  to  all  ex- 
pectations is  taken  by  young  children  with  considerable  delight. 

Mineral  Acids 

Insufficient  attention  is  being  paid  to  the  medicinal  properties  of 
mineral  acids.  Aside  from  its  usefulness  in  anacidity  the  dilute  hydro- 
chloric acid  will  be  found  extremely  serviceable  in  all  protracted  fevers, 
such  as  typhoid  and  in  tuberculosis.  In  anorexia  of  children  dilute 
hydrochloric  acid  combined  with  essence  of  pepsin  and  small  doses  of 
nux  vomica  often  works  wonders.  The  dilute  nitromuriatic  acid  in 
from  2  to  5  drops,  well  diluted,  is  indicated  as  a  preventive  of  the 
so-called  bilious  attacks,  characterized  by  recurrent  vomiting,  head- 
ache and  catarrhal  jaundice,  and  the  syrup  hydriodic  acid  is  an  in- 
valuable remedy  in  all  chronic  bronchial  affections  of  children,  more 
particularly  in  unresolved  pneumonia  and  asthma. 

Alteratives 

Arsenic,  iodine  and  mercury  form  the  standard  remedies  of  this 
group,  and  if  given  in  ample  doses  are  invariably  productive  of 
excellent  results.  The  use  of  arsenic  in  children  is  generally  limited 
to  chronic  blood  affections  and  chorea.  In  blood  diseases  arsenic 
should  be  administered  in  combination  with  iron  either  by  mouth  or 
hypodermically  where  prompt  action  is  desired.  For  this  purpose 
iron  arsenate,  from  gr.  1/4  to  gr.  1,  will  be  found  particularly  bene- 
ficial. From  time  immemorial  arsenic  has  been  lauded  as  a  specific 
in  chorea,  and  all  of  us  have  had  occasion  to  corroborate  this  view. 
It  is  well  to  bear  in  mind,  however,  that  arsenic  is  practically  useless 
in  the  so-called  rheumatic  or  infectious  variety  of  chorea  which  calls 
for  absolute  rest  in  bed  and  salicylates,  and  may  prove  to  be  a  very 
grave  affection  if  procrastinated  by  arsenic  treatment.  In  the  neurotic 
type  of  chorea  Fowler's  solution  may  be  pushed  to  its  full  physiologic 
effect,  provided  the  urine  is  carefully  watched  for  a  possible  renal 
irritation.  Fowler's  solution  in  small  doses  seems  also  to  enhance 
the  therapeutic  value  of  the  bromide  in  the  treatment  of  epilepsy. 

Except  in  syphilitic  affections,  the  syrup  iodide  of  iron  or  hydriodic 
acid  should  be  given  preference  to  potassium  and  sodium  iodide.  More- 
over, it  is  worth  noting  that  the  iodide  per  se,  i.  e.,  without  mercury 
will  never  cure  syphilis,  be  it  congenital  or  acquired.  Hence,  the 
sooner  mercury  is  resorted  to,  the  better  for  the  patient.     The  iodides 


106  DISKA.SES   OF    CHILDREN 

may  be  rendered  more  or  less  palatable  by  means  of  peppermint  or 
orange  flower  water  and  simple  syrup,  or  fluid  extract  of  sarsaparilla 
and  water. 

Mercury  is  the  specific  in  syphilis  and  may  be  administered  in  chil- 
dren by  inunction,  fortified  by  protiodide  of  mercury  internally.  Five 
to  10  gr.  of  a  50  per  cent  unguentum  hydrargyri  in  lanolin,  rubbed 
in  thoroughly  once  a  day,  and  from  1/16  to  1/12  gr.  protiodide  of  mer- 
cury three  times  daily,  will  show  beautiful  results  in  a  very  short  time. 
In  the  beginning  of  the  treatment  it  may  be  necessary  to  administer 
a  few  drops  of  paregoric  daily  to  allay  intestinal  irritation.  In  the 
newborn  with  congenital  syphilis  we  may  at  first  order  1/10  gr.  calomel 
every  three  hours,  and  follow  it  up  with  the  aforementioned  reme- 
dies a  few  weeks  later.  There  is  very  rarely  any  occasion  in  children 
to  use  more  vigorous  methods  of  treatment. 

Antipyretics  and  Antirheumatics 

Water  internally  and  externally  is  the  best  antipyretic  in  children. 
"Whenever  the  temperature  is  ephemeral  in  character,  as  for  example,  in 
indigestion,  tonsillitis  and  the  like,  a  cold  sponge  or  pack  answers 
the  purpose  admirably.  On  the  other  hand,  when  the  temperature 
is  continued  and  recalcitrant  an  effort  must  be  made  to  influence  the 
cerebral  heat  center,  and  this  is  best  accomplished  by  means  of  warm 
tub  baths.  They  tranquilize  the  nervous  system,  equalize  the  circula- 
tion, produce  diaphoresis  and  reduce  the  temperature  without  shock  or 
depression.  However,  in  highly  nervous  children,  antipyretic  drugs, 
such  as  phenacetin,  antipyrin,  etc.,  are  also  indicated,  and  if  given 
in  moderate  doses  at  long  intervals  are  perfectly  harmless.  They  may 
be  made  fairly  palatable  in  syrupus  acaciae  and  orange  flower  water. 
It  may  here  be  emphasized  that  a  moderate  dose  of  an  antipyretic 
will  often  promptly  control  an  attack  of  convulsions  in  children,  at 
any  rate  long  enough  until  its  cause  has  been  determined  and  appro- 
priate remedies  employed  for  its  permanent  removal.  It  is  well  to 
remember  also  that  small  repeated  doses  of  antipyretics,  more  partic- 
ularly pyramidon,  will  frequently  subdue  grotesque  choreic  move- 
ments where  the  usual  treatment  utterly  fails.  The  specific  of  salicyl- 
ates in  rheumatic  affections  is  too  well  known  to  require  reiteration  on 
my  part.  It  may  be  noted,  however,  that  salicylates  are  tolerated  by 
children  in  larger  quantities  than  by  adults,  and  if  administered  with 
a  little  caffeine  sodium  benzoate  or  strophanthus  are  perfectly  free 
from  depressing  after  effects.  On  many  occasions  I  have  had  the  oppor- 
tunity to  convince  myself,  as  well  as  others,  of  the  distinct  abortive 
powers  of  sodium  or  ammonium  salicylate  in  acute  poliomyelitis.    The 


PREVENTION   AND    CONTROL   OF   DISEASE  107 

salicylates  are  also  invaluable  in  all  acute  infections  diseases;  and 
whenever  one  is  in  doubt  as  to  what  medicine  to  prescribe,  one  Avill 
almost  invariably  strike  it  right  by  selecting  this  remedy.  It,  further- 
more, has  the  good  quality  of  being  palatable. 

Hypnotics,  Anodynes  and  Antispasmodics 

The  selection  of  pleasant  hypnotics  and  anodynes  is  rather  difficult, 
and  perhaps  fortunately  so,  since  their  effect  upon  the  delicate  in- 
fantile organism  at  best  is  more  or  less  deleterious.  Very  recently 
I  was  consulted  to  see  a  newborn  supposedly  suffering  from  atelectasis 
pulmonum.  The  baby  was  in  profound  stupor,  its  pupils  markedly  con- 
tracted, its  breathing  from  ten  to  twelve  per  minute,  and  pulse  from 
forty  to  fifty  per  minute,  barely  perceptible.  It  refused  to  nurse  and 
swallowed  with  difficulty.  The  family  physician  informed  me  that  the 
baby  had  been  sneezing  and  coughing,  and  to  relieve  the  anxiety  of 
the  parents  he  had  prescribed  a  cough  mixture  containing  5  minims 
of  paregoric  in  each  dose,  which  was  administered  every  two  hours. 
Obviously  we  were  dealing  with  a  case  of  opium  poisoning.  By 
promptly  directing  the  treatment  against  it  the  infant  recovered  very 
rapidly.  The  safe  dose  of  paregoric  for  children  is  one  drop  for  every 
year  of  the  child's  age,  and  one  tenth  of  this  quantity  when  the  tinc- 
ture of  opium  is  prescribed.  In  gastrointestinal  affections  where  an 
opiate  is  indicated,  preference  should  be  given  to  Dover's  powder 
(one-tenth  of  a  grain  for  every  year  of  the  child's  age),  because  of  the 
beneficial  effect  of  the  ipecac  it  contains ;  and  whenever  vomiting  pre- 
cludes its  administration,  we  will  often  find  an  opium  suppository  to 
act  admirably.  Where  very  prompt  action  is  desired,  as  for  example, 
in  cholera  infantum  with  profuse  vomiting  and  purging,  we  may  ad- 
vantageously resort  to  a  hypodermic  injection  of  morphine  (gr.  1/60) 
and  atropine  (gr.  1/600).  Morphine  and  atropine  hypodermically 
are  occasionally  indicated  also  in  other  acute  diseases,  e.  g.,  uremic 
convulsions.  In  respiratory  affections  codeine  and  its  similar  morphine 
derivatives  are  the  drugs  par  excellence.  Whenever  a  hypnotic  is  in- 
dicated, codeine  added  to  bromide  will  act  by  far  better  than  the  newer 
coal  tar  byproducts.  The  use  of  spasmodics  in  children  is  somewhat 
limited.  In  olden  times  belladonna  was  looked  upon  as  the  sine  qua  non 
in  pertussis.  It  was  pushed  to  its  full  physiologic  effect — until  the 
child  was  practically  blinded.  We  know  better  today.  Belladonna  will 
be  found  useful,  however,  in  ordinary  catarrhs  of  the  respiratory  tract 
with  profuse  mucous  discharge  and  in  rhinitis  of  infants  when  the  nasal 
discharge  interferes  with  nursing.  In  combination  with  codeine,  in  the 
form  of  suppositories,  belladonna  is  of  particular  value  in  irritable 


108  DISEASES   OF    CHILDREN 

bladder,  strangury  and  tenesmus,  and  also  acts  nicely  as  a  palliative  in 
catarrhal  appendicitis,  when  medication  by  mouth  is  contraindicated. 
We  may  choose  hyoscyamus  instead  of  belladonna ;  in  fact,  there  is 
no  better  antispasmodic  and  anodyne  in  dysuria  accompanying  cys- 
titis than  hyoscyamine  sulphate.  The  dose  is  gr.1/800  for  every  year 
of  the  child's  age,  dissolved  in  syrupus  althese  and  water. 

Stimulants 

Practically  all  stimulants  are  unpleasant  in  taste  and  require  skill- 
ful compounding  to  render  them  palatable.  Glycerine  and  the  elixir 
digestivum  compositum  serve  best  in  this  direction.  Strychnine  and 
strophanthus  are  indicated  in  almost  all  infectious  diseases  of  chil- 
dren, and  should  be  administered  early  rather  than  late.  In  the  early 
stage  of  the  disease  the  dosage,  of  course,  should  be  small.  Gr.  1/300 
of  strychnine  and  m.  1  of  tincture  of  strophanthus  for  every  year  of  the 
child's  age  will  ordinarily  serve  the  purpose  admirably.  I  believe  it  is 
a  mistake  to  leave  stimulation  in  pneumonia  to  the  very  end,  and  I 
have  made  it  a  rule  to  give  strychnine  and  ammonium  carbonate  or 
liquor  ammonii  anisatus  the  first  three  days  of  the  disease,  strychnine 
and  strophanthus  the  following  two  or  three  days,  and  digitalis  and  al- 
coholic stimulants  in  the  last  days  when  the  cumulative  effect  of  the 
pneumonia  toxin  is  most  apt  to  undermine  the  cardiac  muscles.  In  ur- 
gent cases  we  are  often  called  upon  to  add  caffeine  sodium  benzoate  and 
even  adrenalin.  It  is  always  a  good  plan  to  provide  the  nurse  with  an 
ample  supply  of  quick  stimulants  for  an  eventual  emergency  during  the 
crisis,  and  I  am  able  to  assure  the  reader  that  at  least  in  one  case  this 
intensive  preparedness  has  worked  wonders.  About  two  years  ago  I 
was  invited  to  see  a  nine  year  old  boy  suffering  from  grippal,  so-called 
wandering  pneumonia  of  two  weeks '  standing  and  complicated  by  double 
otitis  media.  As  the  patient  was  extremely  weak  and  showed  distinct 
signs  of  myocardial  involvement,  I  suggested  to  the  family  physician  to 
supply  the  nurse  with  three  additional  hypodermic  syringes,  one  con- 
taining 10  drops  of  adrenalin,  the  second  5  gr.  of  caffeine  sodium  ben- 
zoate, and  the  third  1/30  gr.  of  strychnine,  so  as  to  be  on  guard  against 
sudden  heart  failure.  The  next  day  another  consultant  was  called 
and  the  day  following  a  third  one.  This  excellent  clinician,  in  his 
laudable  effort  to  ascertain  the  cause  for  the  delayed  resolution,  di- 
rected the  nurse  to  sit  the  boy  up  in  bed  in  order  carefully  to  exam- 
ine the  posterior  portions  of  the  thorax.  While  doing  so  the  patient 
suddenly  flapped  backward,  his  jaws  dropped,  his  pupils  dilated  and 
his  heart  stopped  beating,  in  short  he  seemed  as  dead  as  a  doornail. 
The  physicians  became  terrified,  mortified  and  left  the  sick-room  to  con- 


PREVENTION    AND    CONTROL    OF    DISEASE  109 

vey  to  the  child's  parents  the  dreadful  message  of  the  unfortunate 
event.  In  the  meantime  the  nurse  recovered  sufficient  sense  to  pro- 
ceed with  the  simultaneous  injection  of  the  three  aforementioned  re- 
serve stimulants  in  the  boy's  arm.  To  her  great  delight  she  soon 
noted  a  slight  twitch  of  his  mouth  and  heard  a  faint  fluttering  of  his 
heart,  and  in  another  few  minutes  the  boy  was  himself  again.  Resolu- 
tion set  in  the  following  day.  For  a  number  of  years  past  the  pro- 
fession has  placed  a  great  deal  of  reliance  on  sterile  camphor  oil  as  a 
powerful  stimulant,  more  especially  in  pneumonia.  I  have  used  it  ex- 
tensively and  am  still  resorting  to  it  occasionally,  but  must  frankly 
confess  never  to  have  been  convinced  of  its  utility  and  have  often 
felt  that  the  sorely  tried  patient  ought  to  be  spared  the  pain  and  dis- 
comfort almost  invariably  associated  with  its  hypodermic  adminis- 
tration. Indeed,  I  fear,  that  the  needle  has  been  recently  grossly 
abused,  be  it  in  the  subcutaneous  injection  of  drugs  or  of  an  unlim- 
ited number  of  inert  vaccines  and  serums,  which  in  the  majority  of 
instances  serve  only  to  fill  the  coffers  of  mercenaries.  It  is  my  hope 
that  these  remarks  will  not  be  misunderstood.  While  firmly  believing 
in  the  life  saving  properties  of  antidiphtheritic  and  antimeningococ- 
cic serums  and  the  like,  I  cannot  help  but  feel  that  the  profession 
is  entirely  too  credulous  to  the  exaggerated  threadbare  claims  of 
the  vaccine  manufacturers.  In  treating  heart  disease,  it  is  well  to 
remember  that  while  digitalis  is  the  indispensable  remedy  in  chronic 
cases  with  "ruptured  compensation,"  it  is  more  or  less  harmful  in 
acute  heart  disease,  with  compensation  intact,  when  an  ice  bag  to  the 
precordium  and  small  doses  of  codeine  with  or  without  sodium  salicylate 
are  indicated. 

Heart  Sedatives 

If  ever  there  be  any  need  for  heart  sedatives  in  children,  we  could 
readily  get  along  with  a  minute  dose  of  morphine  or  its  derivatives 
or  possibly  some  coal  tar  product,  such  as  pyramidon.  Aconite,  the 
standby  of  the  homeopath,  similar  to  digitalis  is  a  dangerous  drug  in 
the  hands  of  the  inexperienced.  The  real  indication  for  aconite  is 
supposed  to  be  sthenic  fever,  and  there  are  not  many  children  too 
vigorous  while  ill.  However,  in  homeopathic  doses  and  well  diluted, 
it  probably  can  do  no  harm. 

Emetics 

No  great  effort  need  be  made  to  disguise  the  taste  of  emetics.  The 
wine  of  ipecacuanha,  requiring  but  small  doses,  should  be  preferred 
to  the  syrup,  and  whenever  emesis  is  very  urgent  a  hypodermic  in- 


110  DISEASES   OF    CHILDREN 

jection  of  from  gr.  1/12  to  gr.  1/16  of  apomorphine  will  prove  most 
satisfactory.  It  is  to  be  regretted  that  emetics  are  dropping  into  dis- 
use, for  many  a  case  of  acute  indigestion  in  children  could  promptly 
be  arrested  by  swift  emesis.  It  may  be  worth  mentioning  also  that 
moderate  doses  of  ipecac  are  invaluable  in  whooping  cough  with  pro- 
longed suffocating  paroxysms,  thus  by  emesis  imitating  nature  in 
aborting  the  attack. 

Expectorants 

The  selection  of  suitable  expectorants  requires  good  judgment. 
It  is  useless,  in  fact  harmful,  for  instance  to  prescribe  stimulating  ex- 
pectorants such  as  ammonium  chloride  or  carbonate  in  cases  of  per- 
sistent coughing  arising  from  nasopharyngeal  or  laryngeal  inflamma- 
tion. We  should  rather  be  inclined  to  allay  the  source  of  irritation 
by  local  measures  and  administer  a  sedative  to  relieve  the  cough. 
With  this  object  in  view  excellent  results  are  usually  obtained  from 
daily  instillation  of  from  2  to  5  per  cent  of  argyrol,  solargentum,  or 
silvol  in  the  nose,  and  the  internal  administration  of  creosote  carbonate 
and  codeine,  well  mixed  with  glycerine  mucilage  and  water.  On  the 
other  hand,  when  dealing  with  a  harassing  cough  in  acute  bronchitis  or 
pneumonia  in  which  the  expectoration  is  very  adhesive  and  cohesive, 
scanty  in  amount  and  hard  to  raise,  a  stimulating  expectorant  with 
or  without  wine  of  ipecacuanha  or  compound  syrup  of  squills,  in  the 
majority  of  instances  will  prove  beneficial  to  the  patient  by  assisting 
nature  to  rid  the  lungs  of  effete  material  and  save  the  patient's  energy 
in  the  terrible  battle  ahead  of  him.  In  chronic  bronchitis  and  un- 
resolved pneumonia  satisfactory  results  are  frequently  achieved  from 
ammonium  iodide,  gr.  I/2  to  1  for  every  year  of  the  child's  age,  every 
three  or  four  hours,  or  from  the  syrup  of  hydriodic  acid  or  syrup 
iodide  of  iron.  The  iodides  are  very  useful  also  in  the  exhausting  cough 
accompanying  noncompensating  heart  disease,  and  may  advantageously 
be  combined  with  digitalis  and  an  occasional  dose  of  some  morphine 
derivative. 

Diuretics  and  Diaphoretics 

Water  is  the  most  palatable  and,  in  large  quantities,  the  most  effi- 
cient diuretic  in  bladder  affections.  If  given  hot  and  sweetened  with 
sugar  it  is  also  an  active  diaphoretic  and  should  be  given  in  preference 
to  offensive  diaphoretic  mixtures,  whenever  possible.  When  drugs 
are  needed,  potassium  acetate  and  citrate  generally  serve  well  both  as 
diuretics  and  diaphoretics.  Potassium  citrate  in  combination  with 
hexamethylenamin    acts    specifically    in    pyelocystitis.      Considerable 


PREVENTION   AND    CONTROL    OF    DISEASE  111 

caution,  however,  is  commended  in  the  continued  administration  of  the 
latter,  owing  to  its  tendency  to  i^roduce  hematuria.  Another  excellent 
preparation  is  sodium  benzoate  which  forms  an  ideal  diuretic,  diapho- 
retic and  expectorant  in  the  group  of  symptoms  frequently  encountered 
in  acute  influenza.*  Diuretics  are  practically  useless,  nay,  often  harm- 
ful, in  acute  nephritis  while  the  urinary  tubules  are  obstructed  by 
the  inflammatory  changes.  In  such  cases  we  do  much  better  with  ac- 
tive diaphoresis  by  means  of  packs  and  hot  baths  and  intestinal  flush- 
ing, to  rid  the  system  of  effete  material  without  overburdening  the 
renal  function.  On  the  other  hand,  in  subacute  and  chronic  nephritis, 
diuretics  must  be  resorted  to  whenever  the  excretion  of  urine  is  dimin- 
ished and  a  tendency  towards  dropsy  becomes  manifest.  In  such 
cases  the  liquor  ferri  and  ammonii  acetatis  seems  to  act  exceedingly 
well.  If,  however,  the  dropsy  is  extensive  and  of  cardiac  origin,  we 
always  have  to  fall  back  on  digitalis  and  strophanthus  with  or  with- 
out diuretin  or  theocin  sodium.  Another  indication  for  free  diuresis 
is  pleurisy  with  effusion,  especially  if  the  medication  is  coupled  with 
complete  abstention  from  all  fluids  in  the  diet.  Under  these  condi- 
tions nature  seems  to  absorb  the  fluid  from  the  pleural  sac  to  replen- 
ish the  needs  of  the  human  economy. 

Laxatives  and  Purgatives 

We  are  all  too  familiar  with  the  action  of  castor  oil,  calomel  and 
phenolphthalein  to  require  any  detailed  discussion.  Attention  may 
here  be  directed  to  the  fact  that  there  is  no  particular  reason 
for  giving  calomel  in  divided  doses  and  bothering  the  child  unneces- 
sarily. Any  baby  can  stand  a  grain  of  calomel  without  much  ado. 
Effervescent  citrate  of  magnesia  is  contraindicated  where  there  is 
a  tendency  to  vomit,  the  milk  of  magnesia  being  by  far  preferable. 
Purgatives  and  hydragogues  are  indispensable  in  acute  nephritis  and 
dropsical  effusions  when  the  kidneys  are  unable  to  perform  their  func- 
tion; unfortunately,  however,  all  these  preparations  are  very  disgust- 
ing in  taste  and  require  large  quantities  to  produce  the  desired  effect. 
Rochelle  and  Epsom  salts  may  be  rendered  fairly  palatable  by  the 
addition  to  a  saturated  solution  of  about  a  third  of  its  quantity  of 
glycerine  and  a  few  drops  of  aromatic  spirits  of  ammonia.  The  mix- 
ture may  then  be  administered  in  teaspoonful  doses  at  frequent  in- 
tervals. The  infusum  senns  compositum  may  prove  useful  in  some 
eases,  but  we  must  see  to  it  that  it  is  freshly  prepared.  In  treating 
chronic  constipation  of  children  our  efforts  in  the  direction  of  regula- 
tion of  the  diet  and  induction  of  regular  habits  will  only  too  often  fail, 

♦Influenza  in  Children,  N.  Y.  Med.  Jour.,  June  30,  1900. 


112  DISEASES   OF    CHILDREN 

and  we  are  frequently  called  upon  to  advise  a  suitable  laxative.  Malt 
extract  with  olive  oil,  or  cascara,  or  mineral  oil  will  answer  the  pur- 
pose in  the  majority  of  cases. 

Intestinal  Astringents 

Most  of  us  still  recall  the  sad  time  when  during  the  summer  months 
every  pharmacist  was  stocked  up  with  a  large  exhibition  of  summer- 
eomplaint-mixtures  to  meet  the  great  demands  of  the  season.  For- 
tunately, with  our  advanced  knowledge  of  the  causes  of  the  summer 
diarrheas  of  infants  and  the  methods  of  prophylaxis,  there  is  no  longer 
any  excessive  demand  for  such  preparations.  However,  we  have  not 
as  yet  reached  the  millennium  in  infant  feeding  and  hence  are  still 
called  upon  to  prescribe  the  time  worn,  yet  efficient,  bismuth  and  chalk 
mixtures.  Ordinarily  I  prefer  bismuth  subcarbonate  to  the  subnitrate, 
and  order  to  give  the  patient  from  10  to  20  grains  after  each  evacua- 
tion. In  this  manner  the  dosage  is  controlled  in  accord  with  the 
severity  of  the  diarrhea.  As  already  stated,  in  colitis  and  cognate 
affections  opium  and  ipecacuanha  will  be  found  to  act  most  satisfac- 
torily. Dover's  powder  may  be  made  palatable  by  the  addition  of  pul- 
vis  aromatieus.  The  different  tannin  preparations  are  worthy  of  trial 
only  in  chronic  enteric  affections,  but  here  greater  benefit  will  be 
derived  from  local  treatment,  more  particularly  daily  intestinal  irri- 
gations with  1/2  to  1  per  cent  of  nitrate  of  silver,  in  addition,  of  course, 
to  an  appropriate  diet.  Sodium  bicarbonate  is,  of  course,  the  specific 
in  diarrhea  associated  with  acidosis  or  fat  and  sugar  indigestion,  and 
should  be  given  in  large  doses  by  mouth  as  well  as  per  rectum. 

Gastric  Sedatives 

Last  in  line  but  foremost  in  importance  are  the  gastric  sedatives, 
since  with  a  highly  irritated  stomach,  when  all  food  or  medication  is 
promptly  ejected,  even  a  very  mild  disease  per  se  is  most  apt  gravely 
to  undermine  the  baby 's  power  of  resistance ;  hence,  the  importance  of 
first  of  all  settling  the  stomach.  In  the  majority  of  instances  this 
is  readily  accomplished  by  one  large  dose  of  sodium  bicarbonate,  let 
us  say,  from  30  to  60  grains  in  water  and  followed  up  by  smaller 
quantities  of  bicarbonate  of  soda  and  subcarbonate  of  bismuth  with  or 
without  calomel.  Good  results  are  often  obtained  also  from  the  dif- 
ferent medicated  waters,  such  as  lime,  peppermint  and  bitter  almond 
water  in  cracked  ice  or  1/20  of  a  drop  of  tincture  of  iodine  well 
diluted.  In  recurrent  vomiting  lavage  is  indispensable,  and  in  some 
cases  we  may  even  have  to  resort  to  a  hypodermic  injection  of  mor- 


PREVENTION    AND    CONTROL   OF   DISEASE  113 

phine.  Of  course,  in  all  cases  of  severe  vomiting  careful  attention 
must  be  given  to  its  etiology,  more  particularly  involvement  of  the 
appendix  or  brain,  or  acidosis. 

In  administering  medicines  to  children,  it  is  often  helpful  to  divide 
the  full  dose  in  several  small  doses,  if  need  be,  giving  it  drop  by  drop 
uptil  the  whole  teaspoonful  has  been  taken.  In  this  manner  even  a  most 
irritable  stomach  will  often  retain  the  medication,  whereas  it  would 
otherwise  reject  it. 

In  conclusion  let  me  suggest  the  following  general  rules  to  facilitate 
the  selection  and  administration  of  drugs  to  children : 

1.  Never  prescribe  any  medicine  unless  you  are  convinced  of  its 
necessity;  if  only  a  placebo  is  required,  prescribe  a  palatable  adjuvant. 

2.  Never  prescribe  a  medicinal  preparation  requiring  a  large  quan- 
tity, when  a  small  one  of  the  same  or  an  equally  as  useful  a  drug  will 
do  the  work  just  as  efficiently.  Thank  Heaven,  the  time  is  past 
when  the  greatness  of  the  physician  stood  in  direct  ratio  to  the  quantity 
of  the  concoction  he  ordered. 

3.  Never  prescribe  a  painful  therapeutic  procedure  or  a  nauseous 
mixture  when  the  patient  will  do  equally  as  well — and  surely  much 
better — without  the  unnecessary  pain  and  annoyance. 

Organotherapy 

Organotherapeutics,  though  still  in  the  experimental  stage,  is  rapidly 
assuming  an  enviable  position  in  the  field  of  specific  medication.  This 
is  true  especially  of  the  thyroids,  and  less  so  of  the  suprarenals,  pitui- 
tary and  thymus  glands. 

Their  modus  operandi  upon  the  human  economy — whether  by  regu- 
lation of  metabolism,  or  neutralization  of  specific  poisons — is  still 
shrouded  in  mystery.  It  is  definitely  established,  however,  that  they 
are  all  of  fundamental  importance  to  the  health  and  growth  of  the 
human  organism. 

From  a  therapeutic  point  of  view  the  thyroid  gland  only  has  thus 
far  met  all  expectations.  It  acts  specifically  in  cretinism  and  myx- 
edema, and  is  very  serviceable  also  in  obesity  and  pachydermatoses. 
The  gland  may  be  administered  fresh  (in  soup)  or  dry.  The  dry  prep- 
arations are  usually  given  in  from  I/2  to  3  grain  doses  twice  daily,  un- 
til the  desired  results  have  been  obtained,  and  in  smaller  quantities 
thereafter.  Engrafting  of  the  sheep's  thyroid  in  the  human  body  has 
met  with  some  success.  The  parathyroids  are  generally  employed  (gr. 
Mo  to  1/4)  as  adjuvant  or  substitute  of  the  thyroid. 

The  suprarenal  solutions  are  used  principally  locally  as  hemostatic 
and  astringent,  e.  g.,  epistaxis,  rhinorrhea  of  divers  origin.    Internally, 


114  DISEASES   OP    CHILDREN 

usually  hypodermically  (5  min.  of  a  1:1000  solution)  in  heart  failure 
and  to  abort  a  severe  attack  of  asthma. 

The  pituitary  gland  is  (gr.  1/4)  highly  recommended  in  infantilism, 
in  hay  fever  and  asthma  (topically  as  well  as  internally),  in  diabetes 
insipidus,  enuresis,  and  tympanites  (hypodermically). 

The  therapeutic  application  for  the  thymus  gland  is  thus  far  lim- 
ited to  pronounced  anemias  and  marasmus.  The  results  are  encour- 
aging. 

More  recently  the  pineal  gland  has  been  found  of  service  in  diverse 
forms  of  mental  deficiencies,  especially  Mongolian  idiocy  (p.  718). 

Vitamines 

Vitamines  are  vital  food  substances  belonging  to  a  group  of  organic 
bases  of  unknown  composition  which  seem  to  be  essential  to  metabolism 
and  the  maintenance  of  good  health  and  normal  growth  and  development 
of  the  body.  They  are  believed  to  be  closely  allied  to  hormones  (pan- 
creatic secretin)  and  possibly  also  to  enzymes.  Some  vitamines  are 
soluble  in  water  and  others  in  fat,  the  latter  being  probably  closely  re- 
lated to  lipoids.  It  is  claimed  that  lack  of  vitamines  forms  the  under- 
lying cause  of  rachitis,  scorbutus,  beriberi  and  pellagra,  but  as  yet  there 
is  no  positive  clinical  evidence  to  confirm  this  view,  although  laboratory 
experiments  tend  to  favor  it.  Autolyzed  yeast  (see  p.  517)  is  being  used 
as  a  vitamine  in  the  aforementioned  affections. 


CHAPTER  II 

EXAMINATION  OF  THE  PATIENT 

AND 

SEMEIOLOGY  OF  DISEASE 

A  successful  physical  examination  of  a  child,  especially  of  an  infant, 
calls  for  a  great  deal  of  tact,  patience,  and  careful  scrutiny.  The 
physician  will  do  well  to  train  his  eyes  at  a  glance  to  observe  and  to 
interpret  the  aspects  of  disease.  As  will  be  noted  later,  in  a  large 
number  of  diseases,  the  attitude,  the  facial  hue  and  expression,  the  size 
and  shape  of  the  child  or  of  some  parts  of  the  body  and  finally  the  aspect 
of  the  skin,  teeth,  etc.,  are  often  pathognomonic.  This  general  survey 
is  preferably  made  while  the  patient  is  still  undisturbed,  utilizing  the 
same  time  for  gathering  the  most  essential  points  of  information  per- 
taining to  the  family,  past  and  personal  history  of  the  patient. 

Family  History. — Longevity  of  the  parents,  brothers  and  sisters;  the 
diseases  they  suffered  from,  especially  as  to  tuberculosis,  syphilis  (mis- 
carriages in  the  mother  often  more  decisive  in  the  diagnosis  than  the 
Wassermann  test!),  rheumatism,  heart,  kidney  or  liver  disease,  al- 
coholism, epilepsy,  insanity,  etc. 

Past  History. — Degree  of  maturity  at  birth,  and  mode  of  delivery 
(instrumental  or  otherwise)  ;  condition  soon  after  birth,  particularly  as 
to  signs  of  traumatism,  convulsions,  asphyxia,  deformity,  hemorrhages, 
skin  eruptions,  nasal  catarrh  ("snuffles")  ;  the  diseases  the  patient  suf- 
fered from  at  a  later  period,  e.  g.,  gastrointestinal,  exanthematous,  pul- 
monary; otitis,  rheumatism,  bone  affections,  etc.  Mode  of  feeding  (breast 
or  bottle),  gain  or  loss  of  weight;  time  of  eruption  of  temporary  or  per- 
manent teeth;  the  time  when  the  patient  began  to  sit  up,  stand,  creep 
and  walk.    Peculiarities  of  temper,  etc. 

Present  History. — Age  of  patient. 

Mode  of  onset  of  the  disease  (gradual  or  sudden). 

Fever  (continuous,  remittent  or  irregular). 

Convulsions^  (apparent  cause;  time  of  occurrence;  duration). 

Vomiting^   (during,  after,  or  between  meals;  appearance  of  vomit). 

Skin  eruption^  (location,  duration;  desquamation). 

Diarrhea*  (duration;  frequency  and  appearance  of  the  stools). 


'See  page  669.         'See  page  398. 
*See  page  156.        ■•See  page  157. 

115 


116  DISEASES   OF    CHILDREN 

Constipation"'  (acute  or  haljitual;  appearance  of  the  stools), 

Pain*'  (situation,  duration;  degree  of  severity). 

Cough^  (duration;  paroxysmal  or  croupy;  appearance  of  sputum). 

Dyspnea®  (worse  after  fatigue  or  at  night;  sudden). 

Cyanosis^  (duration;  mode  of  onset — with  convulsions). 

Urinary  disturbance"  (enuresis,  dysuria,  suppression;  appearance  of 
urine). 

Disturbance  of  Sleep  (pavor  nocturnus;  snoring;  twitching;  crying 
from  "starting  pain"). 

Behavior  and  Mental  Capacity^^  (recent  changes,  if  any). 

Condition  of  Special  Senses^^  (defective  vision,  hearing,  etc). 

The  history  taking  completed,  we  next  turn  to  the  physical  examina- 
tion of  the  patient.  This  should  be  systematic,  preferably  with  the 
child  entirely  undressed,  and  if  deemed  necessary,  should  include 
inspection,  palpation,  auscultation,  percussion,  mensuration  and  weigh- 
ing. 

We  usually  begin  with  the  examination  of  the  head,  noting  its 
size  and  shape,  the  condition  of  the  bones  of  the  skull,  its  fontanelles 
and  sutures,  its  attitude;  facial  expression  and  hue;  condition  of  the 
nose,  eyes,  ears,  mouth,  lips,  tongue,  teeth  and  pharynx. 

THE  HEAD 

The  head  is  rarely  normal  in  shape  immediately  after  birth.  The 
scalp  is  swollen,  the  bones  are  often  displaced,  and  here  and  there 
are  bruises  and  ecchymoses,  the  results  of  a  long  and  painful  journey. 
Within  about  a  week,  the  swelling  subsides,  the  bones  adjust  them- 
selves, the  head  becomes  round  or  oval  and  smooth  except  for  the 
markings  of  the  fontanelles  and  sutures. 

The  cranial  circumference  (frqnto-occipital  diameter)  soon  after  birth 
measures  about  13  inches.  The  skull  enlarges  rapidly  up  to  six  months 
old — 17  inches ;  then  more  slowly  about  1  inch  every  year  up  to 
five  years — 21  inches ;  it  then  remains  stationary  in  growth  up  to  adult 
life,  when  it  measures  from  22  to  23  inches. 

The  posterior  fontanelle  closes  by  the  end  of  the  second  month,  the 
anterior  when  the  infant  is  about  eighteen  months  old,  at  the  latest. 

A  healthy  baby  is  able  to  hold  up  the  head  when  about  four  months 
old. 
The  skull  is— 

1.  Asymmetrical,  with  depressions  and  protrusions,  in  caput  succe- 

"See  page  157.    "See  page  138.    'Seepage  119.    "See  pages  705,  753. 
8See  page  118.    "See  page  134.    '"See  page  159.    "See  pages  121,  306. 


EXAMINATION    OF    THE   PATIENT 


117 


daneiim;  meniiigo-  and  encephalocele ;  syphilis;  neoplasms;  abscesses; 
oxycephalia  ("sugar-loaf"  head),  etc. 

2.  Large,  in  hydrocephalus;  hypertrophy  of  the  brain;  rachitis. 

3'.  Small,  in  microcephalus;  porencephalia. 
The  fontanelles  are — 

1.  Closed   late,   in  hydrocephalus;   rachitis;   cretinism;   idiocy;   os- 
teogenesis imperfecta. 

2.  Closed  prematurely,  in  microcephalus;  atrophy  of  the  brain. 


Fig.  6. — Hydrocephalus. 


3.  Distended,  in  active  and  passive  congestions  of  the  brain,  e.  g., 
divers  forms  of  meningitis ;  meningismus ;  hydrocephaloid,  intracranial 
tumors;  cerebral  hyperemia, 

4.  Sunken,  in  wasting  diseases ;  after  great  loss  of  body  fluids ;  after 
lumbar  puncture. 

The  cranial  bones  are — 

1.  Soft  and  thin,  in  chronic  hydrocephalus;  craniotabes. 

2.  Hard  and  thick,  in  syphilis ;  exostosis. 


118 


DISEASES   OF    CHILDREN 


The  sutures  are — 

1.  Widely  separated,  in  hydrocephalus;  intracranial  tumors. 

2.  Prematurely  closed,  in  microcephalus. 

Attitude  of  the  head — 

1.  Retracted,  shaky,  in  general  debility;  macrocephalus;  hydroceph- 
alus; amaurotic  family  idiocy. 

2.  Spasmodically  retracted  (opisthotonos),  in  meningitis;  meningis- 
mus;   encephalitis;   apical  pneumonia. 

3'.  Turned  laterally,  in  torticollis;  hematoma  of  the  sternocleidomas- 
toid muscle;  retropharyngeal  abscess;  cervical  spondylitis;  cervical 
adenitis;  mastoiditis. 

4.  Moving  irregularly,  in  hyperpyrexia;  spasmus  nutans;  chorea; 
habit  spasm.    In  eruptions  of  the  scalp  attended  by  severe  itching. 


Fonticuluj 
occipitalis 


iutura 

lambdoidea 


Suturd 
coronalis 


Tuber  frontale 


iutura  frontalis 
Fig.  7.— Fontanels,     (Leo-Wolf.) 


The  Face 
Facies  dolorosa — 

1.  Face  of  continuous  pain  (eyes  open,  face  wrinkled,  mouth  half 
closed  and  drawn  to  one  side;  moaning  and  whining)  in  divers  acute 
inflammatory  diseases,  e.  g.,  pneumonia,  pleurisy,  rheumatism,  appendi- 
citis. 

2.  Intermittent  pain  (face  distorted,  red,  perspiring;  loud  crying,  toss- 
ing, kicking),  in  colic,  dysuria,  etc.;  vertebral  caries  (''starting  pain"). 
Facies  luctuosa — 

Face  of  sorrow  (forehead  and  face  wrinkled,  face  pale,  emaciated, 
indifferent,  apathetic,  eyes  half  closed),  in  chronic  wasting  diseases, 
especially  tuberculosis,  and  last  stage  of  heart  disease. 


EXAMINATION    OF    THE   PATIENT  119 

Facies  anxiosa — 

Face  of  anxiety  (eyes  glistening,  congested,  red  or  livid,  and  per- 
spiring; alae  nasi  active),  in  orthopnea  from  various  causes,  e.g., 
laryngeal  stenosis,  extensive  pneumonia,  pulmonary  edema ;  in  hysteria. 

Facies  hippocratica — 

Face  of  grave  abdominal  distress,  or  extreme  exhaustion  (face  pale, 
contracted,  corneae  dull,  eyeballs  and  temples  deeply  sunken,  nose 
pinched,  lips  dry,  cyanotic,  and  covered  with  sordes),  in  moribund 
state,  collapse,  cholera  nostras,  peritonitis,  etc. 

Facies  meningitidis — 

Face  of  internal  convulsions  (staring  look  into  distance,  glassy  cor- 
neae, rapidly  changing  complexion  of  the  face),  in  meningitis;  severe 
eclampsia. 

Facies  senilis — 

Face  of  extreme  old  age  (shriveled  fascial  muscles  and  skin,  pointed 
nose,  lusterless  eyes),  in  marasmus;  syphilis;  chronic  hydrocephalus. 

Facies  idiotes — 

Face  of  the  mentally  defective  (senile  features,  open  mouth,  pro- 
truding tongue),  in  all  forms  of  idiocy  and  imbecility;  less  marked 
in  adenoids. 

Facies  sardonica* — 

Face  of  facial  muscular  spasm  (peculiar  **grin,"  proboscis-form 
mouth,  sometimes  foamy),  in  tetanus  and  similar  prolonged  convul- 
sive conditions. 

Facial  hue** — 

1.  Livid,  in  congenital  and  acquired  heart  disease ;  in  pronounced  res- 
piratory difficulty,  e.  g.,  laryngeal  stenosis,  pulmonary  edema,  asthma, 
etc.;  in  cerebral  hyperemia;  sinus  thrombosis;  in  "holding  the  breath." 

2.  Pale,  in  anemia ;  in  acute  and  chronic  wasting  diseases ;  sudden 
pallor,  in  collapse,  e.  g.,  from  exhausting  hemorrhage. 

3.  Waxy,  in  chronic  malaria ;  suppurative  processes ;  chronic  nephritis ; 
malignant  disease. 

4.  Yellow,  in  icterus  neonatorum  or  catarrhalis,  congenital  oblitera- 
tion of  the  bile  duct ;  in  Buhl 's  or  Winkel  's  disease,  in  liver  affections, 
especially  due  to  syphilis. 

5.  Purplish,  in  phthisis  pulmonalis  ("hectic  flush"),  hyperpyrexia; 
pneumonia;  compensating  heart  disease. 

6.  Greenish,  in  chlorosis. 


*See  also  "Facial  Paralysis,"  "Facial  Hemiatrophy,"  "Pertussis,"   "Nephritis,"  "Trichiniasis," 
p.   426,   "Hemiplegia." 

**See  also  "Exanthemata"  and   "Skin   Diseases." 


120  DISEASES   OF    CHILDREN 

7.  Copper-color  {e.g.,  on  forehead),  in  syphilis. 

8.  Bronze  color,  in  Addison's  disease. 

The  Eyes 
The  eyelids  are — 

1.  Edematous,  without  local  infiammation,  in  anemias;  heart  and 
kidney  diseases;  pertussis;  trichiniasis. 

2.  Crusty,  red  and  swollen,  in  acute  and  chronic  inflammation  of  the 
eyelids;  in  pediculosis  of  the  eyelashes;  in  congenital  syphilis  (in  con- 
junction with  rhagades  at  the  canthi,  and  purulent  nasal  discharge), 
in  scrofulosis  (with  keratitis,  excoriation  of  the  upper  lid,  and  adeni- 
tis) ;  red  and  watery,  in  nasal  catarrh,  hay  fever,  and  measles. 

3.  Retracted,  inability  to  lower  upper  lid,  from  loss  of  power  in  the 
palpebral  muscles,  in  facial  paralysis. 

4.  Drooping  (ptosis)  of  upper  lid,  from  inability  to  raise  it,  in 
congenital  defects  of  the  palpebral  levators  or  their  nerve  supply, 
in  local  trauma  ;  in  oculomotor  paralysis;  ophthalmoplegia  (unilateral) ; 
encephalitis  lethargica. 

5.  Spasmodically  contracting,  in  local  inflammatory  processes  of  the 
lids;  in  photophobia;  in  spasmodic  affections,  such  as  chorea  and  tic. 

The  eyeballs  are — 

1.  Congested,  in  inflammatory  processes  of  the  eye,  e.  g.,  keratitis ; 
in  meningitis;  asphyxia. 

2.  Protruding,  in  exophthalmic  goiter;  in  neoplasms  (gumma)  ;  in 
chloroma  (frog-like  appearance). 

3.  Immobile,  partially  or  completely,  in  ophthalmoplegia  (unilateral). 

4.  Turned  laterally  (strabismus)  ;  in  errors  of  refraction;  in  paralysis 
of  the  abducens  (convergent  strabismus)  ;  in  paralysis  of  the  oculomo- 
tor (divergent  strabismus — with  ptosis,  mydriasis,  and  diplopia). 

5.  Oscillating  (nystagmus),  in  hereditary  ataxia;  lesions  of  the  cor- 
pora quadrigemina ;  multiple  sclerosis;  meningitis;  sinus  thrombosis; 
hydrocephalus. 

The  pupils  are — 

1.  Contracted,  unilaterally,  in  paralysis  of  cervical  sympathetic,  e.  g., 
migraine,  cervical  rib  (may  also  be  bilateral),  in  pressure  by  central 
tumor.  Bilaterally,  in  affections  of  the  cervical  cord,  both  sides;  early 
stage  of  meningitis ;  from  the  effects  of  opium  and  its  derivatives,  chloral, 
pilocarpine,  physostigmine,  etc. 

2.  Dilated,  unilaterally,  in  irritation  of  the  cervical  sympathetic,  e.  g., 
migraine;  in  oculomotor  paralysis.  Bilaterally,  in  marked  dyspnea; 
collapse;  from  the  effects  of  atropine,  belladonna,  hyoscyamus,  cocaine, 
etc. 


EXAMINATION    OF    THE   PATIENT 


121 


3.  Unequal,  in  unilateral  contraction  or  dilatation,  as  aforementioned ; 
in  unilateral  pontine  lesion,  and  in  apoplexy, 

4.  Immobile,  in  adhesions  of  the  iris  to  the  lens;  in  eclampsia;  in  le- 
sions of  the  corpora  quadrigemina ;  in  tabes  dorsalis  (immobility  to  light, 
but  responding  to  accommodation — Argyll  Robertson  pupil). 

Vision  is — 

1.  Diminished,  in  errors  of  refraction;  miosis;  mydriasis;  hysteria; 
acute  eye  affections,  e.  g.,  iritis,  retinitis,  etc. ;  in  corneal  opacities,  cata- 
ract, etc. ;  congenital  eye  defects,  e.  g.,  albinism,  cataract,  irideremia ;  in 
toxic  amblyopia,  e.  g.,  overdoses  of  quinine,  tobacco ;  congenital  amblyo- 
pia (usually  unilateral)  ;  optic  neuritis, 

2,  Lost,  temporarily  or  permanently,  in  uremic,  diabetic,  or  other 
forms  of  toxemia;  in  severe  convulsions  of  central  origin;  congenital 


Fig,  8. — Diagram  of  the  visual  tract.     N.  Lesions  producing  nasal  hemianopia.     L. 
Lesions  producing  lateral  hemianopia,  T.  Lesions  producing  temporal  hemianopia. 


complete  cataract;  amaurotic  family  idiocy  (gradual  onset)  ;  in  embolism 
of  the  central  retinal  artery  (unilateral)  ;  local  injuries;  optic  atrophy, 

3,  Double  (diplopia),  in  peripheral  palsies  of  the  eye  muscles,  e.g., 
after  diphtheria,  influenza,  herpes  zoster  ophthalmicus  (unilateral)  ;  in 
strabismus.  In  orbital  palsies,  through  outside  pressure,  e.  g.,  neoplasms. 
In  central  palsies  (affecting  the  eye  on  the  opposite  side).  In  nuclear 
palsies,  e.g.,  of  the  abducens  (involving  the  eye  on  the  same  side). 

4.  Half,  i.  e.,  blindness  of  one-half  of  the  visual  field  (hemianopsia)  ; 
lateral  or  homonymous,  in  lesions  of  the  optic  tract  between  chiasm  and 
cortex;  temporal,  in  disease  of  the  optic  chiasm  affecting  the  anterior 
or  posterior  angles;  nasal,  in  disease  of  the  chiasm  affecting  the  outer 
angles  (Fig.  8), 


122  DISEASES   OP    CHILDREN 

The  Ears 

Abnormalities  of  the  ears  and  adjacent  structures — 

1.  Asymmetry  of  the  ears,  in  congenital,  mentally  defectives. 

2.  Tumefactions,  at  and  about  the  ear,  in  the  external  meatus,  in 
furuncles,  abscesses,  and  local  traumatism.  In  front  of  the  ear,  in 
epidemic  parotitis  (often  bilateral,  though  not  simultaneously)  ;  in 
secondary  parotitis  (complicating  diseases  of  the  mouth,  local  infec- 
tion in  the  vicinity ;  acute  infectious  diseases,  e.  g.,  typhoid ;  in  new 
growths.  Behind  and  downward,  pushing  the  auricle  forward,  in  mas- 
toiditis ;  in  perforating  abscesses  of  the  external  auditory  canal ;  in  pre- 
auricular lymphadenitis,-  and  much  less  marked  in  glandular  fever. 

Hearing  is — 

1.  Diminished,  at  a  distance,  but  not  by  bone  conduction,  in  ex- 
ternal and  middle  ear  disease,  in  occlusion  of  the  auditory  canal  by 
foreign  bodies,  e.g.,  cerumen,  furuncles;  or  outside  tumors,  e.g.,  paro- 
titis ;  in  nasopharyngeal  disease,  e.  g.,  adenoids. 

2.  Lost,  temporarily  or  permanently,  both  at  a  distance  and  by  bone 
conduction,  in  congenital  defects  of  the  auditory  apparatus;  in  com- 
pression (by  intracranial  tumors)  or  atrophy  of  the  auditory  nerve; 
in  disease  of  the  pons  or  cerebellum  which  has  spread  to  the  fourth 
ventricle;  in  amaurotic  family  idiocy. 

3.  Disturbed  by  noises  (tinnitus  aurium),  in  foreign  bodies  in  the 
auditory  canal,  e.  g.,  cerumen,  mycosis,  myringitis ;  in  catarrh  of  the 
Eustachian  tube;  in  otitis  media;  neuroses;  epilepsy,  and  mental  affec- 
tions. 

The  Nose 

Abnormalities  of  the  nose  in  structure  and  function — 

1.  Saddle-shaped,  sunken,  in  hereditary  syphilis ;  in  traumatism, 

2.  Compressed  and  pointed,  in  nasal  obstruction,  chiefly  adenoids. 

3.  Pinched  and  pale,  in  collapse;  sudden  fright;  phthisis  pulmonum. 

4.  Purplish  in  color,  in  circulatory  and  respiratory  difficulties,  e.  g., 
pneumonia,  heart  disease. 

5.  Hyperactivity  of  the  alas  nasi,  in  grave  dyspnea. 

6.  Nasal  voice  or  cry,  in  nasal  obstruction,  e.  g.,  adenoids,  rhinitis, 
retropharyngeal  abscess;  in  diphtheritic  paralysis;  in  ulceration  of  the 
nasal  bones,  especially  in  syphilis. 

Nasal  discharg*e — 

1.  Serous,  transparent,  later  mucous,  in  acute  simple  rhinitis 
("cold");  measles;  hay  fever. 

2.  Serosanguinolent,  later  purulent,  in  diphtheritic,  scarlatinal,  and 


EXAMINATION   OF    THE   PATIENT  123 

syphilitic  rhinitis;  in  the  presence  of  foreign  bodies  in  the  nose;   in 
scrofulosis. 

3.  Mucopurulent  or  purulent,  in  severe  acute  rhinitis ;  in  putrid  in- 
fection; in  sinusitis. 

4.  Hemorrhagic  (epistaxis)  in  nasal  trauma ;  inflammation  of  the 
nasal  mucosa;  nasal  polypus;  adenoids;  hemophilia;  vicarious  menstru- 
ation ;  passive  congestion  of  the  brain ;  increased  vascular  tension,  e.  g., 
hyperpyrexia  (especially  if  sudden,  as  it  is  apt  to  be  at  the  onset  of  ex- 
anthematous  diseases),  heart  and  lung  diseases,  pertussis,  influenza; 
in  diseases  of  the  blood,  e.  g.,  sepsis ;  leukemia,  etc. 

The  Lips 
The  lips  are — 

1.  Excoriated  (upper  lip)  from  acrid  nasal  discharge,  in  acute  and 
chronic  affections  of  the  nose,  e.  g.,  rhinitis,  adenoids ;  in  scrofulosis ; 
syphilis, 

2.  Covered  by  herpes,  a  vesicular  eruption  (usually  the  upper  lip  at 
the  angle  of  the  mouth)  in  ordinary  "colds";  in  pneumonia;  in  menin- 
gitis cerebrospinalis. 

3.  Cracked  and  scarified,  especially  at  the  angles  of  the  mouth,  in 
syphilis  hereditaria;  but  also  in  burns  (usually  unilaterally). 

4.  Covered  by  sordes,  in  septic  infections ;  in  typhoid  fever, 

5.  Rosy  in  color,  in  good  health. 

6.  Deep  red,  in  compensating  heart  disease. 

7.  Purple,  in  marked  dyspnea,  from  respiratory  and  circulatory  dis- 
turbances, 

8.  Pale,  in  divers  forms  of  anemia, 

9.  Livid,  in  heart  failure, 

10.  Dirty,  soot-like,  in  sepsis;  typhoid  fever;  ulcerative  stomatitis. 

The  Oral  Cavity 
The  mouth  is — 

1.  Drawn  to  one  side,  droops,  in  facial  paralysis,  especially  when 
the  facial  muscles  are  brought  into  action ;  in  progressive  facial  hemi- 
atrophy; in  hemiplegia. 

2.  Drawn  outward  and  downward,  with  the  lips  pointed  forward, 
proboscis-like,  in  trismus  neonatorum,  tetanus  and  tetany. 

3.  Broad  and  grinning,  in  cretinism;  idiocy. 

4.  Large  from  birth,  in  maerostomia;  small  and  contracted,  in  micro- 
stomia; in  congenital  syphilis;  from  the  effect  of  burns, 

5.  Open  habitually  ("mouth-breathing")  in  nasal  obstruction;  ade- 
noids; idiocy;  retropharyngeal  abscess. 

6.  Twitching,  spasmodically,  in  chorea ;  habit  spasm. 


124  DISEASES   OF    CHILDREN 

Fetor  ex  ore — 

1.  Stale  insipid,  in  catarrh  of  the  nasopharynx;  dental  caries;  in  feb- 
rile diseases ;  chronic  dyspepsia. 

2.  Putrefactive,  at  short  range,  in  divers  forms  of  simple  stomatitis; 
acute  indigestion.  At  a  distance,  in  noma;  malignant  diphtheria  or 
scarlatinal  angina. 

3.  Sulphuretted  hydrogen  odor,  in  fetid  bronchitis ;  pulmonary  gan- 
grene. 

4.  Acetone  odor,  in  diabetes;  cyclic  vomiting;  acidosis. 

5.  Ammoniacal  odor,  in  uremia. 

6.  Chloroform,  ether,  alcohol,  etc.,  odors,  from  the  effects  of  these 
drugs. 

In  irritable  children  it  is  preferable  to  postpone  the  examination 
of  the  mouth-cavity  until  the  other  portions  of  the  body  have  been 
thoroughly  examined,  since  the  undue  excitement  usually  created  by 
the  inspection  and  palpation  of  the  mouth  and  throat  of  the  patient 
greatly  interferes  with  the  study  of  the  other  physical  phenomena. 
Through  daily  practice,  the  physician  soon  learns,  almost  at  a  glance, 
to  distinguish  the  abnormal  from  the  normal;  until  he  has  acquired 
this  skill,  however,  he  should  examine  the  contents  of  the  oral  cavity 
slowly  and  systematically. 

The  gums,  teeth,  floor  and  roof  of  the  mouth ;  the  tongue,  buccal 
mucous  membrane,  the  uvula,  fauces,  tonsils  and  posterior  pharynx — 
all  should  receive  careful  attention. 
The  gums  are — 

1.  Whitish,  thin,  and  hard,  normally  in  early  infancy. 

2.  Eeddened,  slightly  swollen  and  painful  to  touch,  before  erup- 
tion of  teeth. 

3.  Spongy,  swollen,  and  prone  to  bleed,  in  divers  forms  of  sto- 
matitis ;  in  scurvy ;  purpura ;  in  other  grave  constitutional  diseases,  such 
as  leukemia. 

4.  Purulent,  receding,  from  the  teeth,  in  pyorrhea  alveolaris;  al- 
veolar abscess. 

5.  Bleeding,  without  inflammatory  symptoms,  in  hemophilia. 

6.  Colored  blue,  forming  a  blue  line  along  the  margin  of  the  gum, 
in  lead  poisoning. 

The  temporary  teeth  are  twenty  in  number,  and  under  normal  condi- 
tions generally  appear  in  groups,  at  variable  intervals,  as  follows: 

1.  Two  lower  central  incisors  at  the  age  of  from  six  to  eight  months. 

2.  Four  upper  incisors  (2  central,  2  lateral)  from  eight  to  ten 
months. 

3.  Two  lower  lateral  incisors  from  eleven  to  twelve  months. 


EXAMINATION    OF    THE   PATIENT 


125 


4.  Four  anterior  molars  (2  upper,  2  lower)  from  fourteen  to  six- 
teen months. 

5.  Four  canines  (2  upper,  2  lower)  from  eighteen  to  twenty  months. 

6.  Four  posterior  molars  (2  upper,  2  lower)  from  twenty-two  to 
thirty  months. 

Abnormal  teething — 

1.  Dentitio  tarda,  i.  e.,  considerable  retardation  (absence  of  a  tooth 
at  the  age  of  a  year  or  later),  in  rickets;  general  debility;  congenital 
syphilis ;  cretinism ;  idiocy,  etc. 

CENTRAL 

:i  NCI  Softs  ■; 


Fig.  9. — Temporary  and  permanent  teeth. 


2.  Dentitio  precox  is  of  no  special  significance.  Occasionally  occurs 
in  congenital  syphilis  (a  tooth  may  appear  soon  after  birth)  ;  in  hydro- 
cephalus. 

3.  Irregular  implantation,  incurvation,  striation  and  premature  ero- 
sion, the  same  as  in  "dentitio  tarda"  (g.  v.). 

The  permanent  teeth  appear  normally  in  the  following  order : 

1.  Four  first  molars  (2  upper,  2  lower)   at  about  six  years. 

2.  Four  central  incisors  (2  upper,  2  lower)  at  about  seven  years. 


126  DISEASES   OF    CHILDREN 

3.  Four  lateral  incisors  (2  upper,  2  lower)  at  about  eight  years. 

4.  Four  anterior  bicuspids  (2  upper,  2  lower)  at  about  nine  years. 

5.  Four  posterior  bicuspids  (2  upper,  2  lower)  at  about  ten  years. 

6.  Four  canines  (2  upper,  2  lower)  at  about  eleven  years. 

7.  Four  second  molars  (2  upper,  2  lower)  at  about  twelve  to  fif- 
teen years. 

8.  Four  third  molars  (2  upper,  2  lower)  at  about  seventeen  to 
twenty-five  years. 

Abnormalities  of  the  permanent  teeth — 

1.  Increased  vulnerability  and  brittleness,  in  divers  grave  constitu- 
tional affections,  e.  g.,  rickets,  profound  anemia ;  in  neglect  and  injury 
of  the  teeth,  especially  by  escharotic  drugs  for  cleansing  of  the  teeth 
or  medicinal  purposes  {e.g.,  the  tincture  chloride  of  iron,  acids). 

2.  Asymmetry,  in  harelip;  cretinism  and  other  forms  of  defective 
mentality;  nasal  obstruction;  "mouth  breathing";  thumb  sucking. 

3.  Looseness,  in  gingivitis;  ulcerative  stomatitis;  mercurialism ; 
scurvy;  pyorrhea  alveolaris. 

4.  Hutchinson's  teeth,  i.e.,  peg-shaped,  dwarfed  upper  central  inci- 
sors, notched  in  their  cutting  edge,  in  inherited  syphilis. 

5.  Microdentism,  small  white  transparent  teeth,  not  abnormal,  but 
occasionally  seen  in  children  of  syphilitic  parents. 

6.  Amorphism,  tendency  of  teeth  assuming  abnormal  shape  {e.g., 
incisor  taking  the  shape  of  canine)  frequently  in  syphilis,  but  also  in 
nonsyphilitic  children. 

The  floor  of  the  mouth  may  present — 

1.  Adhesio  linguae,  a  frequent  cause  of  difficult  suckling;  and  later 
of  difficult  speech. 

2.  Sublingual  ulcer,   in   protracted   coughing,   especially   pertussis. 

3.  New  growths,  e.  g.,  ranula,  fibroma  sublinguale;  in  salivary  cal- 
culi ;  inflammatory  swelling. 

The  palate  is — 

1.  Highly  arched  and  asymmetrical,  in  divers  forms  of  mental  de- 
generacy; adenoids. 

2.  Defective  or  perforated,  in  congenital  clefts  of  the  palate;  in 
syphilitic  or  gangrenous  processes  {e.g.,  diphtheria,  scarlatina). 

3.  Red,  velvety,  in  scarlatina. 

4.  Punctiform  or  stellate,  in  measles  or  rotheln. 

5.  Vesicular  with  red  areola,  in  chickenpox. 

6.  Papular,  in  smallpox. 

7.  Whitish-yellow  eroded  dots  over  the  hamular  process  of  the  palate 
bone,  in  Bednar's  aphth«e. 


EXAMINATION   OF    THE   PATIENT 


127 


8.  Minute,    yellowish-white    milia,    in    "epithelial    pearls"    (on    both 
sides  of  raphe  near  the  junction  of  the  hard  and  soft  palates). 

9.  White  specks  or  scattered  patches,  in  different  forms  of  stomatitis. 

10.  Hemorrhagic  and  punctiform,  in  hemorrhagic  diathesis;  tubercu- 
lous and  cerebrospinal  meningitis;  pernicious  blood  affections. 

The  buccal  mucous  membrane  presents  in  addition  to  the  discolorations 
occurring  upon  the  palate,  also  the  following: 

1.  Brownish,  greenish  or  gray  ulcer,  in  incipient  noma, 

2.  Red  spots  with  central,  rounded,  slightly  elevated,  bluish  efflores- 
cence (Koplik's  spots),  in  measles. 


Fig.  10. — Ulcerative  stomatitis  involving  also  the  lips  and  adjacent  structures. 


The  tongue  is — 

1.  Large,  in  congenital  macroglossia ;  in  cretinism;  idiocy;  glossitis. 

2.  Furred,  in  all  acute  and  protracted  forms  of  gastroenteritis;  feb- 
rile diseases;  nasopharyngeal  catarrh. 

3.  Red,  in  scarlatina  (strawberry  tongue);  stomatitis;  glossitis;  gas- 
tritis (hyperacidity), 

4.  Yellow,  in  biliousness;  liver  disease;  chronic  intestinal  indigestion. 

5.  Pale,  in  anemia. 


128  DISEASES   OP    CHILDREN" 

6.  Gray,  brown,  and  somewhat  black,  with  red  border  and  tip,  in  ty- 
phoid fever,  in  sepsis. 

7.  Black,  in  profound  sepsis,  in  collapse  impending  death. 

8.  Livid,  in  general  cyanosis;  congenital  heart  disease;  severe  pneu- 
monia. 

9.  Spotted,  desquamating,  in  geographical  tongue;  hyperpyrexia; 
stomatitis. 

10.  Fissured,  in  glossitis  desiccans;  hyperpyrexia;  burns. 

11.  Ulcerated,  in  severe  forms  of  stomatitis ;  in  syphilis ;  tuberculosis ; 
traumatism  (biting  of  the  tongue  during  an  epileptic  fit;  irritation  by 
carious  teeth). 

12.  Dry,  in  mouth-breathing;  excessive  thirst  {e.g.,  hyperpyrexia, 
diabetes) ;  in  sepsis. 

13.  Protruding,  in  macroglossia   {e.g.,  idiocy,  cretinism). 

14.  Drawn  to  one  side,  in  paralysis  of  the  hypoglossal  nerve  (toward 
the  diseased  side)  ;  in  peripheral  facial  palsy  (toward  the  healthy  side). 

15.  Tremulous,  in  hyperpyrexia ;  debility ;  chorea ;  disseminated  lateral 
sclerosis;  bulbar  paralysis. 

The  saliva  is — 

1.  Increased  in  quantity,  in  mercurialism ;  stomatitis;  teething; 
idiotic  conditions. 

2.  Diminished  in  quantity,  in  fever ;  from  the  effects  of  atropine,  etc. ; 
parotitis;  glossitis. 

The  uvula — 

May  be  elongated ;  the  seat  of  a  deposit  which  may  extend  from  the 
tonsils  or  from  the  buccal  mucous  membrane  {e.g.,  stomatitis). 

The  tonsils  are — 

1.  Enlarged,  in  divers  forms  of  amygdalitis;  diphtheria;  scarlatina; 
pharyngitis;  influenza;  rheumatism;  abscess;  traumatism;  glandular 
fever;  foreign  bodies  {e.g.,  calculi);  new  growths  {e.g.,  fibrous  poly- 
pus, hydatid  cyst). 

2.  The  seat  of  a  deposit,  in  follicular  tonsillitis  (small  isolated  white 
pellicles  which  coalesce) ;  in  parenchymatous  tonsillitis  (at  first  white, 
later  yellowish  green,  resembling  ''point  of  abscess")  ;  in  tonsillitis  her- 
petiformis (vesicular  deposit,  ending  in  ulcer)  ;  in  necrotic  tonsillitis 
(yellowish-green  patch)  ;  in  influenza  and  pharyngitis  (superficial  exu- 
dation) ;  in  scarlatina  and  diphtheria  (large  pseudomembrane)  ;  in 
stomatitis  mycotica  (fiour-like  deposit). 

In  doubtful  cases  it  is  imperative  to  examine  a  smear  of  the  tonsillar 
deposit  microscopically  or  bacteriologically. 


EXAMINATION    OF    THE    PATIENT  12!) 

The  Neck 

The  lymphatic  glands  are — 

Enlarged,  in  all  forms  of  angina,  especially  that  due  to  diphtheria 
or  scarlet  fever;  in  affections  of  the  mouth  (e.  g.,  stomatitis,  gingivitis)  ; 
in  parotitis;  mastoiditis;  rubella;  glandular  fever;  pseudoleukemia; 
scrofulosis  (tuberculosis)  ;  eczema  capitis;  local  infections;  nasal  affec- 
tions. 

The  thyroid  giand  is — 

1.  Enlarged,  in  goiter,  exophthalmic  goiter;  endemic  goitrous  cre- 
tinism ;  thyroiditis ;  temporarily,  Ijefore  menstruation. 

2.  Atrophied  or  absent,  in  sporadic  cretii^ism. 
Tumefactions  (other  than  those  of  the  glands  of  the  neck)  — 

1.  Hematoma  of  the  sternocleidomastoid,  in  the  center  or  at  sternal 
insertion  of  the  sternocleidomastoid  Muscle. 

2.  Hygroma  cysticum,  between  lower  jaw  and  clavicle,  attains  enor- 
mous size. 

3.  Fistula  colli  congenita,  at  sternoclavicular  articulation. 

Pulsation  of  the—  ^*    *'    ■  ' 

1.  Arteries,  in  heart  disease;  hyperpyrexia. 

2.  Veins,  especially  in  tricuspid  insufficiency. 
Stiffness  of  neck  (See  "Attitude  of  Head,"  p.  118). 

THE  THORAX  AND  ITS/CONTENTS 

J  Auscultation  and  Percussion 

Auscultation  is  best  performed  hj  a  small  biaural  stethoscope,^  since 
with  this  instrument  every  inch  of  the  infantfie  thorax  can  be  thor- 
oughly examined  and  small  circumscribed  lesi(|)is  readily  detected. 

Normally  the  respiratory  sound  is  puerile  (^ugh  vesicular)  in  in- 
fancy or  early  childhood ;  and  vesicular  in  old^er  children. 

In  auscultating  the  infantile  lungs  we  should  remember  the  follow- 
ing peculiarities:  1.  During  quiet  respiration  the  inspiratory  sound 
is  fairly  audible,  while  the  expiratory  sound  is  but  slightly  so ;  hence 
to  obtain  more  distinct  physical  signs  it  is  of  advantage  to  disturb  the 
infant,  or  to  make  it  cry.  2.  Owing  to  the  larger  diameter  of  the  right 
bronchus,  the  respiratory  sounds  are  louder  on  the  right  side  than  on  the 
left.  3.  Pure  bronchial  breathing  is  often  normally  heard  over  the 
interscapular  regions,  especially  to  the  right  of  the  spinal  column.  4. 
Adventitious  sounds  originating  in  the  nasopharynx  and  larynx  are 
frequently  transmitted  to  the  chest  and  may  be  misinterpreted  as  signs 
of  pulmonary  disease. 


130 


DISEASES   OF    CHILDREN 


The  normal  pulmonary  percussion  note  is  clear,  loud,  and  somewhat 
tympanitic.  It  is  somewhat  metallic,  when  the  child  cries ;  cracked-pot- 
like, over  the  right  subclavicular  region;  somewhat  dull  over  the  areas 
overlapping  the  liver,  heart  and  spleen. 

Percussion  of  the  infantile  hmgs  should  be  practiced  while  the  patient 
is  held  in  a  sitting  posture  (watch  heart  action!)  perfectly  still  and  as 
erect  as  possible.  It  should  be  performed  gently,  preferably  during  the 
height  of  inspiration  and  expiration.    Every  portion  of  the  lungs  should 


Fig.    11, — The    thoracic    and    abdominal    regions. 

S.  Inguinal. 


1.    Hypochondriac.      B.    Lumbar. 


be  carefully  gone  over,  paying  especial  attention  to  the  sub-  and  supra- 
clavicular spaces,  which  are  not  rarely  the  seat  of  consolidation,  and 
the  area  corresponding  to  the  tracheal  bifurcation,  which  is  often  the 
seat  of  tuberculization  of  the  bronchial  glands.  The  physical  signs 
are  not  always  conclusive,  if  percussion  is  performed  too  forcibly  (may 
give  rise  to  covibration  of  the  more  distant  parts)  ;  if  the  child  cries 
(during  the  act  of  crying  compression  of  the  lungs  by  ascension  of  the 
diaphragm  produces  artificial  dullness);  if  the  position  of  the  child  is 


EXAMINATION    OF    THE   PATIENT 


131 


faulty  {e.  g.,  lying  on  tlie  abdomen  pushes  the  diaphragm  upward  and 
compresses  the  lungs) ;  or  if  the  thorax  is  bent  sharply  forward. 

In  auscultating  the  heart  we  should  bear  in  mind  the  following:  1. 
Accentuation  of  the  first  sound  is  heard  equally  as  well  at  the  arterial 
and  venous  orifices.  2.  Accentuation  of  the  second  sound  is  ordi- 
narily not  heard  until  about  the  age  of  puberty.  3.  Both  heart  sounds 
are  louder  in  children  than  in  adults  and  are  more  widely  transmitted. 
4.  Reduplication  of  the  heart  sounds  is  not  uncommon,  and  generally 
the  result  of  excitement.     5.  In  infants  hemic  murmurs  are  rare.     6. 


Fig.  12. — The  regions  of  the  back.  A.  Suprascapular  or  supraspinatus.  B. 
Scapular.  C.  Interscapular.  D.  Infrascapular  or  lower  dorsal.  E.  Lumbar.  F. 
Sacral. 


The  heart  beat,  as  to  frequency  and  rhythm,  is  apt  to  undergo  great 
variations  on  the  slightest  provocation. 

Percussion  of  the  child's  heart  should  be  performed  very  gently  while 
the  patient  sits  (watch  heart  action!)  quietly  and  bent  slightly  for- 
ward. The  data  obtained  on  percussion  while  the  child  cries,  holds  its 
breath,  etc.,  are  not  wholly  to  be  depended  upon,  since  during  bodily 
unrest  the  heart  is  very  apt  to  change  its  relation  to  the  chest  wall. 


132  DISEASES   OF    CHILDREN 

The  same  holds  true  in  the  event  of  the  heart  being  overhipped  by 
emphysematous  lungs;  or  if  the  heart  is  left  bare  by  atrophy  of  the 
adjacent  lung  portions,  or  by  displacement  or  retraction  of  the  heart 
or  lungs  by  pleuritic  or  pericardial  adhesions. 

THE  THORAX 

The  normal  infantile  thorax  is  round  and  somewhat  cylindrical,  its 
sagittal  and  transverse  diameters  being  nearly  equal.  As  the  child 
grows  older,  the  chest  assumes  a  more  conical  shape,  until,  at  puberty, 
it  resembles  that  of  the  adult.  The  chest  w^all  of  the  child  is  thin, 
elastic  and  yielding,  owing  to  incomplete  development  of  the  muscu- 
lar and  bony  structures.  The  ribs  of  the  infant  are  nearly  horizontal. 
The  measurements  of  the  thorax  are — 

In  the  newly  born  infant,  about  131/2  inches. 

At  one  year,  18  inches. 

At  three  years,  20  inches. 

At  six  3^ears,  23  inches. 

At  twelve  years,  26  inches. 

At  the  end  of  the  fifteenth  year,  the  measurement  of  the  circum- 
ference of  the  chest  is  about  half  of  that  of  the  body  length. 

Up  to  about  eighteen  months  the  circumference  of  the  chest  nearly 
equals  that  of  the  head.  If  from  the  end  of  the  second  year  on 
the  circumference  of  the  head  exceeds  that  of  the  chest,  there  is  a 
strong  suspicion  of  hydrocephalus,  marked  rachitis  and  contraction 
of  the  chest  through  pulmonary  disease  or  imperfect  development  (ade- 
noids). On  the  other  hand,  if  the  chest  measurement  in  early  child- 
hood by  far  exceeds  that  of  the  head,  it  is  indicative  either  of  an  ab- 
normality of  the  chest,  e.  g.,  distention  by  fluids,  or  of  congenital  mal- 
development  of  the  head,  e.  g.,  microcephalus,  infantilism. 
Abnormal  shapes  of  chest — 

1.  Barrel-shape  (deep,  short  and  broad),  in  emphysema,  and  the 
lung  affections  which  precede  it,  e.  g.,  asthma,  pertussis ;  protracted 
laryngeal  stenosis. 

2.  Flask-shape  (flat,  narrow  and  long),  in  phthisis  pulmonum;  naso- 
pharyngeal stenosis,  especially  adenoids. 

3.  Funnel-shape  (marked  depression  in  lower  portion  of  sternum),  in 
rachitis;  Barlow's  disease;  also  congenital. 

4.  Pigeon-  or  chicken-breast-shape  (protrusion  of  median  portion 
of  sternum  and  flattening  of  sides  of  chest),  in  rachitis;  congenital  heart 
disease. 


EXAMINATION    OF    THE    PATIENT  133 

5.  Unilateral  bulging,  in  pneumothorax ;  pleurisy  or  pericarditis  Avith 
effusion ;'tumor;  scoliosis  (opposite  side), 

6.  Unilateral  flattening,  in  pleuritis  retrahens  (after  absorption  of 
fluid);  pulmonary  contraction,  e.g.,  tuberculosis;  after  pyothorax  op- 
eration ;  scoliosis. 

Tumefactions — 

1.  Costal,  nodular,  in  rachitis  (rachitic  rosary);  tuberculous  and 
sj'philitic  processes;  multiple  exostoses. 

2.  Intercostal,  doughy,  in  suppuration  of  the  bronchial  glands;  em- 
pyema necessitatis ;  lung  hernia. 

3.  Mammary,  in  mastitis;  cold  abscess;  as  a  partial  manifestation 
of  parotitis ;  new  growths. 

Abnormal  posture  of  scapulae — 

1.  Prominent,  uni-  or  bilaterally,  "angel-wing"  deformity,  in  con- 
genital malformation;  in  emaciation.  Unilaterally,  in  scoliosis;  paraly- 
sis of  the  scapular  muscles,  e.  g.,  after  local  trauma ;  poliomyelitis ;  pro- 
gressive atrophy. 

2.  Sunken,  after  empj-ema  operation ;  in  scoliosis. 
Activity  of  the  thorax  in  breathing — 

1.  Increased,  bilaterally,  in  asthma ;  laryngeal  obstruction ;  unilat- 
erally, on  the  sound  side,  in  pleurisy  with  effusion,  pneumothorax ; 
fixed  deformities. 

2.  Diminished,  bilaterally,  in  emphysema ;  hydrothorax ;  diffuse  tu- 
berculization; paralytic  conditions  of  the  chest  wall;  sclerema;  col- 
lapse ;  unilaterally,  in  pleurisy  with  effusion  ;  pneumothorax ;  pleuro- 
dynia;  pleuropneumonia  with  "stitch  pain." 

Pain  on  pressure — 

1.  Superficial,  in  rheumatism  of  the  chest  muscles;  intercostal  neu- 
ralgia; affections  of  the  ribs  (caries,  periostitis,  fracture,  etc.)  ;  local- 
ized abscesses  (empyema  necessitatis) ;  and  tumefactions  (e.  g.,  masti- 
titis). 

2.  Deep,  in  pleurisy  ;  pneumonia  ;  phthisis  pulmonalis. 

The  Lungs* 

The  lungs  are  normally  fully  distended  with  air  within  the  first 
few  hours  of  life.  In  the  premature  or  delicate  infant  full  lung  in- 
flation may  not  occur  until  several  weeks  after  birth.  The  lower  lobes 
particularly  may  remain  in  a  state  of  atelectasis. 

The  normal  houndwries  of  the  lungs  differ  somewhat  with  the  age 
of  the  child.     On  both  sides  they  project  with  their  summits  into  the 


'See    "Auscultation"    and    '"I'ercussion,"    \>.    129. 


134  DISEASES   OF    CHILDREN 

supraclavicular  fossae.   From  here  they  descend  in  the  following  manner : 
The  right  lung-  (lower  border)  lies — 

In  the  sternal  line  at  a  point  corresponding  to  the  fifth  (upper  bor- 
der) rib. 

In  the  parasternal  line  at  a  point  corresponding  to  the  fifth  (lower 
border)  rib. 

In  the  mammary  line  at  a  point  corresponding  to  the  sixth  rib. 

In  the  axillary  line  at  a  point  corresponding  to  the  seventh  rib. 

In  the  scapular  line  at  a  point  corresponding  to  the  tenth  rib. 

The  left  lung  (lower  border)  lies — 

In  the  sternal  line  at  a  point  corresponding  to  the  fourth  rib. 

In  the  parasternal  line  at  a  point  corresponding  to  the  fourth  rib. 

In  the  mammary  line  at  a  point  corresponding  to  the  sixth  rib. 

In  the  axillary  line  at  a  point  corresponding  to  the  seventh  or  eighth 
rib. 

In  the  scapular  line  at  a  point  corresponding  to  the  tenth  rib. 

Posteriorly,  the  base  of  the  left  lung  is  slightly  lower  than  that  of 
the  right  lung. 

Number  of  respirations  per  minute — 
In  the  newborn,  from  35  to  40. 
At  the  end  of  the  first  year,  30. 
At  the  end  of  the  second  year,  25. 
At  six  years,  22. 
At  twelve  years,  20. 

Character  of  respiration — 

1.  Abdominal,  in  children  under  four  years  of  age. 

2.  Costoabdominal,  in  children  (male  and  female)  up  to  ten  years; 
in  the  male,  in  older  ones. 

3.  Thoracic,  in  girls  over  ten  years. 

4.  Regularity  of  respiratory  rhythm  is  usually  not  fully  established 
before  the  age  of  two  years. 

Abnormalities  of  respiration — 

1.  Increased  frequency,  in  respiratory  and  circulatory  diseases  (see 
"difficult  breathing");  pyrexia;  emotional  excitement;  compression  of 
the  lungs  by  an  accumulation  of  gas ;  fluids,  or  solid  masses. 

2.  Diminished  frequency,  in  grave  central  disease;  extreme  weak- 
ness; poisoning  from  belladonna,  opium,  etc. 

3.  Costal  breathing  in  boys  over  ten  years  old,  and  increased  cos- 
tal breathing  in  girls,  in  inflammatory  diseases  of  the  abdominal  and 
pleural  cavities  (by  interference  with  the  action  of  the  diaphragm) 


EXAMINATION   OF   THE   PATIENT 


135 


iTERNAL  UN[ 
PARASTERNAL  LINt 
MAMMARr  LINE 


Fig.  13. — Diagnostic  lines  of  the  thorax. 


Fig.  14. — Anterior  boundaries  of  the  lungs. 


rig.  15. — Posterior  boundaries  of  the  lungs. 


136  DISEASES    OF    CHILDREN 

e.  g.,  peritonitis,  pleuritis ;  in  abdominal  distention  by  gases,  fluids,  or 
solid  masses;  in  paralysis  of  the  diaphragm,  e.  g.,  bulbar  paralysis,  polio- 
encephalitis, neuritis  (postdiphtheritic)  of  the  phrenic  nerve;  in  drug 
poisoning;  in  hysteria. 

4.  Purely  abdominal  breathing,  especially  in  girls  over  ten  years  old, 
in  emphysema ;  scleroderma ;  paralj^sis  of  respiratory  muscles,  e.  g.,  bul- 
bar paralysis,  poliomyelitis. 

5.  Irregular  breathing,  in  conditions  associated  with  "difficult  breath- 
ing"; in  cerebrospinal  affections;  in  atelectasis;  painful  diseases  of  the 
respiratory  muscles  ;  in  hysteria. 

6.  Stertorous  breathing,  in  nasopharyngeal  obstruction,  e.  g.,  retro- 
pharyngeal abscess,  adenoids;  in  uremic  or  apoplectic  coma. 

7.  Cheyne-Stokes '  breathing,  occasionally  in  infants  during  sleep;  in 
heart  failure  from  divers  causes;  in  meningitis,  especially  the  tubercu- 
lous variety ;  in  meningeal  hemorrhage,  tumors  or  abscess  exerting  pres- 
sure upon  the  brain ;  in  drug  poisoning,  e.  g.,  opium ;  in  death  agony, 

8.  Difficult  or  labored  breathing  (dyspnea),  in  laryngeal,  tracheal  or 
broncliial  obstruction  from  divers  causes,  e.  g.,  croup,  diphtheria,  large 
thymus,  asthma,  etc. ;  in  affections  associated  with  diminution  of  the 
usual  pulmonary  breathing  area,  such  as  active  or  passive  congestion, 
e.  g.,  pneumonia,  pleurisy  or  pericarditis  with  effusion,  compression  or 
displacement  by  neoplasms,  deformities  of  the  thorax,  advanced  pul- 
monary tuberculosis ;  in  grave  circulatory  disturbance  inducing  deficient 
oxygenation  of  the  blood  or  obstruction  to  pulmonary  circulation,  e.  g., 
blood  or  heart  diseases  ("cardiac  asthma")  ;  in  conditions  giving  rise 
to  "irregular  breathing"  (q.v.),  "stertorous  breathing"  {q.v.),  and 
"Cheyne-Stokes'  breathing"  (q.v.,),  in  neuroses,  e.g.,  hysteria,  neuras- 
thenia— asthma  hystericum. 

Abnormal  respiratory  sounds — 

1.  Vesicular,    exaggerated,   in   bronchial    inflammation ;    atelectasis. 

2.  Weak,  in  thickened  pleura ;  moderate  pleuritic  effusion ;  emphy- 
sema. 

3.  Absent,  in  extensive  pleuritic  effusions. 

4.  Bronchial,  over  the  seat  of  the  lesion,  in  pneumonia ;  tubercu- 
lization; above  the  seat  of  lesion,  in  compression  of  the  lung  by  tumors 
in  the  chest  cavity  or  pleuritic  exudates. 

5.  Amphoric,  in  smooth-Avalled  cavities;  open  pneumothorax. 
Abnormal  secretory  sounds — 

1.  Dry,  sibilant  and  sonorous  rhonchi,  in  bronchitis;  asthma  (wheez- 
ing and  whistling). 

2.  Dry,  crackling,  in  incipient  phthisis  (apex)  ;  beginning  of  second 
stage  of  pneumonia. 


EXAMINATION    OF    THE    PATIENT  I'M 

3.  Moist,  large  and  medium-sized  rales,  in  bronchitis  (larger  bron- 
chial tubes)  with  abundant  secretion;  in  cavities. 

4.  Moist,  small  rales,  in  capillary  bronchitis. 

5.  Moist,  crepitant  (fine)  rPdes,  in  croupous  pneumonia  (crepita- 
tio  indux  or  redux;  catarrhal  pneumonia;  capillary  bronchitis  (in  con- 
junction with  coarse  rales);  tuberculization;  pulmonary  edema  (in 
conjunction  with  larger  moist  rales). 

6.  Metallic  tinkling,  in  pneumothorax. 

7.  Metallic  splashing  or  gurgling,  in  sero-  or  pyopneumothorax. 

8.  Friction  sound,  in  pleuritis  sicca;  pleuropneumonia;  miliary  tu- 
berculosis.   It  is  not  altered  by  coughing,  as  is  the  case  with  rales. 

Vocal  resonance* — 

1.  Diminished,  in  bronchitis  with  free  secretion;  pleurisy  with  ef- 
fusion ;  obstruction  of  bronchial  tubes ;   emphysema ;   pneumothorax. 

2.  Increased,  in  tuberculization;  pneumonia  (over  consolidation). 

3.  Bronchophony  (concentration  of  voice  near  the  ear),  in  tuberculi- 
zation; pneumonic  consolidation;  compressed  lung  above  pleuritic  ef- 
fusion; l)ronchia]  dilatation. 

4.  Exaggerated  broaichial  whisper;  the  same  as  for  bronchophony 
iq.v.). 

5.  Pectoriloquy  (complete  transmission  of  sound),  the  same  as  for 
bronchophony  (q.v.). 

6.  Amphoric  voice  ("the  echo"),  in  large  cavity;  pneumothorax. 

7.  Egophony,  bleating  (goat-like  resonance  of  voice),  in  pleurisy  with 
effusion  (near  upper  boundary  of  dulness)  ;  pleuropneumonia;  hydro- 
thorax. 

Abnormal  percussion  resonance — 

1.  Dull,  or  diminished  resonance,  in  pneumonia  ;  tubercle  ;  neoplasms; 
pulmonary  gangrene;  pulmonary  abscess  with  thick  masses;  pleuritic 
thickening ;  atelectasis. 

2.  Flat  or  absence  of  resonance,  in  pleurisy  with  effusion;  hydro- 
thorax  ;  hemothorax.  Resonance  may  alter  with  change  of  patient 's 
position.  Also  in  last  stage  of  pneumonia  with  extensive  consolida- 
tion. 

3.  Tympanitic,  or  drum-like,  resonance,  in  tuberculosis  (cavities)  ; 
open  pneumothorax;  lung  atrophy;  above  pericardial  or  pleuritic  ex- 
udations or  near  neoplasms — the  result  of  increased  air  pressure;  pul- 
monary edema ;  moderate  emphysema. 

4.  Ami)horie,  metallic,  or  concentrated  tympanitic  sound,  in  large 


*Vocal    resonance   elicited    on   auscultation    corresponds    to   vocal    fremitus   as   obtained   by   jial- 
pation.      l''reniitns  is   increased   in   consolidation,   and   diminished   in   effusions. 


138  DISEASES   OP    CHILDREN 

tuberculous  cavity  with  solid  and  tense  walls  lying  close  to  the  chest 
wall;  occasionally  heard  in  healthy  child  during  crying. 

5.  Cracked-pot  resonance,  in  pulmonary  cavity  communicating  with 
the  bronchial  tubes — usually  in  tuberculosis;  may  be  elicited  also  in 
healthy  child  during  talking  or  singing. 

6.  Bandbox  note  (abnormally  loud  and  deep),  in  pronounced  emphy- 
sema; pneumothorax  with  strong  tension  of  the  chest  wall. 

Cough 

It  is  essentially  a  reflex  act  arising  from  direct  or  indirect  irrita- 
tion of  the  respiratory  center.  In  a  measure  it  can  be  voluntarily  pro- 
duced or  suppressed.  The  ability  to  cough  is  lost  in  paralysis  of  the 
cricoarytenoid  or  the  respiratory  muscles;  hence  cessation  of  cough- 
ing— with  plenty  of  mucus  in  the  bronchial  tubes — particularly  in  pul- 
monary disease,  is  considered  a  bad  omen.  The  nature  of  the  cough 
may  often  be  decided  upon  from  its  character. 
The  cough  is  usually — 

1.  Short  and  somewhat  hoarse,  in  nasopharyngeal  catarrh  and  ade- 
noids. 

2.  Loud  and  barking,  in  laryngitis  and  spasmodic  croup. 

3.  Dull,  barking  and  somewhat  moist,  in  ulceration  of  the  larynx 
(diphtheria,  syphilis,  etc.). 

4.  Dry,  tight  and  w^histling,  in  early  bronchitis. 

5.  Soft,  deep,  and  loose,  in  advanced  bronchitis. 

6.  Paroxysmal  and  whooping,  in  pertussis  and  other  spasmodic  affec- 
tions; tuberculosis  of  the  bronchial  glands. 

7.  Hemming,  in  incipient  phthisis  and  in  nervousness. 

8.  Short,  sharp  and  painful,  in  pneumonia,  pleurisy,  and  cardiac  dis- 
ease. 

9.  Deep  and  distressing,  in  chronic  phthisis,  asthma,  emphysema, 
etc. 

Too  much  reliance  should  not  be  placed  upon  the  character  of  the 
cough,  as  it  is  very  apt  to  vary  with  the  duration  of  the  cough,  medi- 
cation and  complications.  By  far  more  reliable  information  can  be 
obtained  from  a  careful  examination  of  the  expectoration. 

Sputum,  Expectoration 

In  cases  where  the  children  cannot  or  will  not  expectorate,  the 
sputum  may  be  obtained  by  introducing  into  the  throat  a  sterile 
cotton  swab  or  fenestrated  stomach  tube — both  of  which  usually  re- 


EXAMINATION    OF    THE   PATIENT  139 

ceive  enough  of  sputum  during  the  act  of  coughing  to  suffice  for  or- 
dinary examination. 

The  expectoration  is — 

1.  Mucous,  frothy,  grayish -white,  in  acute  catarrh  of  the  air  pas- 
sages. 

2.  Mucopurulent,  tenacious,  yellowish-gray,  in  chronic  tracheo- 
bronchial catarrh;  in  pertussis  (voluminous,  often  mixed  with  vomi- 
tus)  ;  in  asthma  (Curschmann's  spirals,  Charcot's  crystals)  ;  in  bron- 
chiectasis (periodic  ''mouthful  expectoration,"  separable  into  a  puru- 
lent and  mucoserous  layer). 

3.  Purulent,  fetid,  dirty  grayish-green,  in  fetid  or  putrid  bronchi- 
tis (separable  into  three  layers;  suspended  in  the  lowest,  purulent 
layer  are  Dittrich's  plugs);  in  pulmonary  abscess  (separable  into  two 
distinct  layers,  containing  a  great  number  of  micrococci,  elastic  fibers, 
fat  crystals,  etc.)  ;  in  pulmonary  gangrene  (same  as  putrid  bronchitis, 
plus  tissue  fragments). 

4.  Serous,  prune-juice-like,  and  profuse,  in  pulmonary  edema, 

5.  Bloody,  in  nasopharyngeal  catarrh  Avith  violent  paroxysms  of 
coughing  (occasional  streaks  of  blood)  ;  in  foreign  bodies  in  the  air 
passages  (bright  red  mixed  with  frothy  mucus)  ;  in  pneumonia  (uni- 
formly stained,  "rusty"  sputum  to  dark  ''prune  juice"  color  with 
pneumococci)  ;  in  influenza  (often  bright  red  and  profuse) ;  in  heart 
disease  with  edema  (the  same  as  in  pulmonary  edema  from  other 
causes;  besides  "heart-cells");  in  tuberculous  lesions  of  the  air  pas- 
sages (either  large  hemorrhage,  "hemoptysis,"  or  blood  stained  "num- 
mular" and  heavy  sputum,  containing  tubercle  bacilli);  in  neoplasms 
("red  currant"-like  sputum,  with  characteristic  histologic  structures); 
in  vicarious  menstruation;  hemorrhagic  diathesis,  and  hysteria.  (See 
"Hematemesis"  and  "Epistaxis.") 

The  expectoration  contains  numerous  microorganisms  and  occa- 
sionally bile  (icterus),  hydatid  booklets,  distomum  pulmonale,  and 
cercomonas. 

The  Heart* 

The  heart  is  comparatively  larger  in  infancy  than  in  later  life.  It 
is  relatively  largest  at  birth,  and  smallest  at  about  the  age  of  seven 
years.  At  birth  the  walls  of  both  ventricles  are  nearly  of  equal 
thickness,  but  as  the  infant  grows  older,  the  left  ventricle  rapidly 
gains  in  thickness,  so  that  by  the  end  of  the  second  year  it  is  almost 
twice  as  thick  as  the  right  ventricle. 


*See  "Auscultation"  and  "Percussion,"  p.   129. 


140 


DISEASES   OP    CHIIiDREN 


Corresponding    to   the   relatively    larger    size    and    more    transverse 
position  of  the  heart  of  the  young  child,  its  boundaries  are  greatly 
at  variance  from  those  of  the  heart  of  the  adult. 
The  boundaries  of  the  normal  heart— 
The  apex  heat  is  situated — 

To  the  left  of  the  mammary  line,  in  the  fourth  intercostal 

space,  up  to  the  fourth  year  of  age. 
At  the  mammary  line,  slightly  below  the  fifth  rib,  up  to  the 

eighth  year. 


Fig.  16. — Normal  lieart  of  a  child  three  years  old. 

Slightly  to  the  right  of  the  mammary  line,  in  the  fifth  inter- 
costal space,  up  to  the  twelfth  year. 

Between  the  mammary  and  parasternal  lines,  i.  e.,  the  same 
as  in  the  adult,  in  children  over  twelve  years. 
The  Relative  "heart  dulness"  in  infants  is  boiinded  as  follows: 

Above,  by  a  line  corresponding  to  the  lower  border  of  the 
second  rib. 


EXAMINATION    OF    THE   PATIENT 


141 


On  the  left  side,  l)y  a  line  ])arallel  and  slightly  to  the  left 

of  the  left  maniniary  line. 
On  the  right  side,  by  the  right  parasternal  line. 
Below,  by  a  somewhat  semicircular  line  along  the  fifth  rib. 
As  the  child  grows  older  and  the  heart  assumes  a  more  oblique  and 
lower  position,  the  boundaries  of  the  relative  heart  dulness  gradually 
fall  in  line  with  those  of  the  adult. 

The  absolute  ''heart  dulness"  in  infants  is  bounded  as  follows: 
Above,  by  the  upper  border  of  the  fourth  rib. 
On  the  left  side,  by  the  left  mammary  line   (slightly  to  the 
right  of  it). 


Fig.  17. — Normal  heart  of  a  child  eight  years  old. 


On  the  right  side,  by  the  left  sternal  line. 

Below,  by  a  line  corresponding  to  the  upper  border  of  the 
fifth  rib. 
These  boundaries,  like  those  of  the  relative  heart  dulness,  change 
gradually  with  the  advance  of  the  child's  age,  so  that  in  children  over 
twelve  years  old,  the  upper  boundary  is  formed  by  the  fourth  rib ;  the 
lower  by  a  line  drawn  parallel  to  and  between  the  fifth  and  sixth  ribs ; 
on  the  right  side,  by  the  sternal  line ;  and  on  the  left  by  a  line  midway 
between  the  parasternal  and  mammary  lines.     (See  Figs.  18,  19,  and  20.) 


142 


DISEASES   OF    CHILDREN 


The  normal  pulse  rate  (most  reliable  when  patient  is  asleep )- 
In  the  newborn  from  120  to  150  per  minute. 
At  one  year  old,  100  to  120  per  minute. 
At  four  years,  90  to  100  per  minute. 
At  eight  years,  80  to  90  per  minute. 
At  twelve  years,  75  to  80  per  minute. 


PARASTERNAL 
LINE 


MAMMARY 
-  LINE 


Fig.  18. — Up  to  four  years. 


PARASTERNAL 
LINE 


PARASTERNAL 
LINE 

MAMMARY 
LINE 


Fig.  19. — Up  to  eight  years.  Fig.  20. — Up  to  twelve  years. 

The  relative  and  absolute  heart  dulness  at  different  ages. 

Normal  pulse  respiration  ratio  is  approximately  1:4.    A  ratio  of  1 :3  or 
less  is  a  certain  indication  of  pulmonary  disease,  especially  pneu- 
monia. 
Apex  beat — 

1.  Displaced — 

Outward,  to  the  left,  in  hypertrophy  of  the  right  ventricle ; 
dilatation  of  the  right  ventricle;  right-sided  pleurisy  with 
effusion;  right-sided  pneumothorax;  abdominal  distention 
pushing  the  diaphragm  upwards  and  the  heart  to  the  left. 
Outward  and  downward,  in  hypertrophy  of  the  left  ventri- 
cle; dilatation  of  the  left  ventricle;  pericardial  effusion; 
congenital  or  acquired  (by  pressure  from  above,  e.  g.,  tu- 
mor or  abscess)  dislocation  of  the  heart. 


EXAMINATION   OP    THE   PATIENT  143 

Inward,  to  the  right,  in  left-sided  pleuritic  effusion ;  pro- 
nounced left-sided  deformity  of  the  thorax;  persistence 
of  the  embryonic  position  or  situs  mversus  (up  to  dextro- 
cardia). 

2.  Effaced  {i.  e.,  apex  beat  is  invisible  and  barely  palpable),  in  obes- 

ity ;   pericardial   effusion ;   heart   failure ;    emphysema ;   edema 
cutis ;  tumors. 

3.  Diffuse  and  weak  in  irregularity  of  the  heart  associated  with 

grave  heart  disease. 

4.  Diffuse  and  strong,  in  cardiac  hypertrophy;  hyperpyrexia;  over- 

stimulation ;  excitement.    The  cardiac  impulse  may  only  appear 
strong  when  the  chest  wall  is  very  thin. 
Heart  sounds — 

Accentuation  of — 

1.  Systolic  mitral,  in  excitement;  fatigue;  fever;  hypertrophy 

of  the  left  ventricle. 

2.  Diastolic  pulmonic,  in  hypertrophy  of  right  ventricle. 

3.  Diastolic  aortic,  in  hypertrophy  of  left  ventricle. 
Weakening  of — 

1.  Systolic  mitral,  in  dilatation  of  the  left  ventricle;  loss  of 

compensation. 

2.  Diastolic  pulmonic,  in  dilatation  of  the  right  ventricle  (e.  g., 

relative  tricuspid  insufficiency)  ;  stenosis  of  pulmonary  ar- 
tery. 

3.  Diastolic  aortic,  in  aortic  stenosis. 

Division  (double)  of  diastolic  at  apex,  in  mitral  stenosis;  adhesive 
pericarditis. 

Gallop  rhythm,  in  heart  failure  from  various  causes  (e.  g.,  incipient 
diphtheritic  paralysis)  ;  noncompensating  heart  disease ;  tachy- 
cardia. 

Metallic  ringing,  in  pneumopericardium ;  pneumothorax ;  large  pul- 
monary cavity;  intense  meteorism. 
Heart  murmurs — 

1.  Systolic,  loudest  at  apex  and  transmitted  to  axilla  and  angle 

of  left  scapula,  in  mitral  regurgitation. 

2.  Systolic,  loudest  at  base   (midstemum)   and  transmitted  to 

the  arteries  upward  and  sometimes  over  the  whole  ster- 
num, in  aortic  obstruction, 

3.  Systolic,  at  base,  but  not  transmitted  upward,  in  pulmonic 

obstruction. 

4.  Systolic,  loudest  at  ensiform  cartilage,  in  tricuspid  regur- 

gitation. 


144 


DISEASES   OF    CHILDREN 


5.  Diastolic,  loudest  at  base,  and  transmitted  to  apex  and  ensi- 

form   cartilage,   in   aortic   regurgitation. 

6.  Diastolic,  or  presystolic,  loudest  at  apex,  in  mitral  obstruc- 

tion. 

7.  To-and-fro-friction,  superficial,  limited  to  precordinm;  not 

influenced  by  respiration  (as  is  the  case  in  pleuritis  sicca), 
in  fibrinous-  pericarditis. 


Fig.  21. — Topography  of  cardiac  valves.  Points  of  transmission  of  heart  nmrmurs. 
A.  0.  Aortic  obstruction.  P.  0.  and  B.  Pulmonic  obstruction  and  regurgitation.  A. 
R.  Aortic  regurgitation.  T.  0.  and  B.  Tricuspid  obstruction  and  regurgitation.  M. 
0.  Mitral  obstruction.    M.  B.  Mitral  regurgitation. 


Areas  of  heart  dulness — 
Enlarged — 

1.  To  the  left,  in  hypertrophy  or  dilatation  of  the  left  ventricle. 

2.  To   the  right,   in   hypertrophy   or   dilatation   of   the   right 

ventricle. 

3.  Bilaterally,   in  pericardial   effusion.     The   area   of   dulness 

is  larger  in  sitting  than  in  recumbent  posture;  it  is  often 
triangular;  wider  below  than  above. 


EXAMINATION    OF    THE   PATIENT  145 

Reduced — 

In  pulmonary  emphysema ;  pneumopericardium. 

Displaced — 

1.  In  congenital  malpositions,  e.  g.,  dextrocardia,  mesocardia, 

diaphragmatic  hernia. 

2.  In  acquired  affections,  such  as  pneumothorax;  pleurisy  with 

effusion ;  neoplasms ;  pleuritic  retraction ;  atrophy  of  the 
lungs. 

The  pulse — 

1.  Frequent,  in  fright;  excitement;  fear;  febrile  diseases  (except 

uncomplicated  typhoid  or  meningitis) ;  valvular  heart  diseases 
(except  aortic  stenosis)  ;  anemias,  especially  on  slight  exertion; 
tachycardia;  exophthalmic  goiter;  convalescence  from  acute 
affections;  paralysis  of  the  heart  (central  or  peripheral  paral- 
ysis of  pneumogastric  nerve);  heart  failure  {e.g.,  collapse  in 
febrile  diseases). 

2.  Slow,  in  uncomplicated  typhoid  fever  or  meningitis;  after  crises 

{e.g.,  pneumonia)  ;  acute  nephritis;  catarrhal  jaundice;  intra- 
cranial pressure    {e.g.,  hydrocephalus,  hemorrhage,  tumors); 

heart  disease,  such  as  aortic  stenosis,  myocarditis ;  bradycardia ; 
profuse  hemorrhage;  marked  inanition  {e.g.,  a  pyloric  steno- 
sis) ;  opium  poisoning. 

3.  Irregular,  in  last  stages  of  valvular  heart  disease ;  myocarditis ; 

profound  anemia   (on  exertion);  nervous  palpitation;  indiges- 
tion (flatulent  colic). 
In  the  irregular  pulse  we  distinguish  the — 

1.  Intermittent  pulse — 

Pulsus  alternans  (every  second  beat  weak). 
Pulsus  bigeminus  (every  third  beat  weak). 
Pulsus  trigeminus  (every  fourth  beat  weak). 

2.  Intercidens  pulse  (several  regular  beats  suddenly  followed  by  a 

small  beat  and  pause),  in  heart  weakness. 

3.  Paradoxic  pulse   (the  pulse  grows  smaller  or  ceases  entirely  on 

deep  inspiration),  in  adhesive  pericarditis;  constriction  of  the 
air  passage ;  mediastinal  tumors ;  during  ' '  whoop ' '  in  pertussis. 

4.  Dicrotic  or  double  pulse  (in  part  explained  by  a  loss  in  the  mus- 

cular tone  in  the  arteries,  so  that  the  arterial  impulse  is  sepa- 
rated from  that  of  the  ventricles  by  a  perceptible  interval),  in 
typhoid  fever  and  less  marked  in  other  acute  febrile  diseases ;  in 
chronic  wasting  diseases,  especially  tuberculosis ;  in  anemias ;  af- 
ter great  loss  of  blood. 


146 


DISEASES   OF    CHILDREN 


5.  Asymmetric  (radial)  pulse,  in  congenital  anatomic  variations  of 
the  artery  on  one  side ;  acquired  narrowing,  compression ;  or 
cicatricial  contraction  of  the  radial,  brachial,  axillary,  sub- 
clavian or  innominate  artery;  aneurysm  of  the  aforementioned 
arteries  or  of  the  aorta ;  in  pneumothorax  compressing  the  sub- 
clavian artery. 

THE  ABDOMEN  AND  ITS  CONTENTS 

In  order  to  save  time,  inspection  and  palpation  of  the  abdomen  may 
at   once  be  supplemented  by   percussion,   succussion,    etc.     To   judge 


Fig.  22. — The  thoracic  and  abdominal  regions.     1.  Hypochondriac.     ^.  Lumbar. 

3.  Inguinal. 

matters  correctly  we  should  bear  in  mind  the  normal  relations  of  the 
abdominal  parietes  to  the  underlying  structures. 

The  abdominal  wall  is  moderately  arched ;  readily  compressible  with- 
out undue  resistance  or  pain;  moves  slightly  upward  and  downward 
quite  evenly  and  regularly  with  inspiration  and  expiration;  and  on 


EXAMINATION    OF    THE   PATIENT  147 

percussion  yields  a  loud,  tympanitic  sound  over  all  portions  of  the 
abdomen  engaged  by  the  intestines. 

The  stomach  at  birth  is  nearly  cylindrical  and  lies  obliquely  in  the 
abdominal  cavity.  Thus,  the  cardiac  end  on  a  level  with  the  tenth  dorsal 
vertebra,  and  the  pyloric  end  in  the  median  line  and  slightly  to  the 
right,  midway  between  the  tip  of  the  xiphoid  cartilage  and  the 
umbilicus.  The  pylorus  is  not  palpable.  Gradually  the  fundus  increases 
in  size  (at  seven  months  it  is  twice  the  original  length)  and  the  stomach 
assumes  a  transverse  position  in  such  a  manner  that  five-sixths  of  its 
volume  occupies  the  left  half  of  the  abdomen  and  one-sixth  the  right. 
The  capacity  of  the  stomach  varies,  of  course,  with  the  age  and  size 
of  the  child,  as  fully  given  when  discussing  ''infant  feeding"  p.  55. 
The  stomach  empties  itself  in  breast  fed  babies  in  two  hours;  in  arti- 
ficially fed  in  three  hours.  The  stomach  is  dilated  in  congenital  py- 
loric stenosis  (shown  by  the  bismuth  radiogram  test,  see  Fig.  58)  ;  also  in 
general  atony. 

The  infantile  intestines,  especially  the  small  intestine,  are  relatively 
longer  than  those  of  the  adult.  At  birth  the  small  intestine  is  about 
9  feet  long,  the  large  intestine  about  18  inches,  the  sigmoid  flexure 
forming  about  half  of  the  colon.  The  capacity  of  the  infantile  intes- 
tines is  relatively  greater  than  in  the  adult,  but  their  musculature  is 
thinner  and  weaker,  hence  the  tendency  to  constipation  and  colic. 
The  intestines  are — 

1.  Dilated,  in  megacolon  congenitum;  above  constriction  in  stenosis 

or  atresia;  intussusception;  chronic  constipation;  prolonged  me- 
teorism. 

2.  Contracted,  below  the  seat  of  constriction;  compression  by  ab- 

dominal tumors. 

The  liver  of  the  newborn  is  relatively  very  large  in  size,  much  larger 
than  in  the  adult,  constituting  in  the  former  about  one-eighteenth,  and 
in  the  latter  about  one-thirty-sixth  of  the  entire  body  weight. 

As  the  child  grows  older  the  size  of  the  liver  is  greatly  reduced,  but 
owing  to  the  sloping  course  of  the  lower  ribs  the  liver  appears  con- 
siderably larger  than  it  actually  is. 
Normal  boundaries  of  the  liver  (as  determined  by  percussion)  — 

1.  Upper  border,  at  midsternal  line,  base  of  ensif  orm  cartilage ;  mam- 

mary line,  sixth  rib;  midaxillary  line,  eight  rib;  scapular  line, 
tenth  rib. 

2.  Lower  border,  parasternal  line,  seventh  rib ;  mammary  line,  about 

1/2  inch  below  free  border  of  the  ribs;  midaxillary  line,  tenth 
rib ;  scapular  line,  eleventh  rib. 

3.  Left  border,  joins  lower  absolute  heart  dulness. 


148 


DISEASES   OP    CHILDREN 


4.  Right  border,  joins  the  right  kidney. 

Its  position  varies  greatly  with  the  ascent  and  descent  of  the  dia- 
phragm— rises  with  expiration  and  descends  with  deep  inspiration.  In 
the  same  manner  it  rises  with  intestinal  meteorism  and  descends  with 
overdistention  of  the  Inngs  through  disease,  e.  g.,  emphysema  or  pneu- 
mothorax. 


Fig.  23. — Dissection  of  still-born  child.     Note  tlie  relatively  large  size  of  the  liver; 
note  also  peculiar  course  of  sigmoid.     (Henry  Enos  Tuley.) 

The  liver  is — 

1.  Enlarged,  in  congenital  syphilis;  tumors;  or  cysts;  liver  abscess; 

chronic  heart  disease;  acute  septic  processes;  abdominal  tuber- 
culosis; splenomegaly  (Gaucher)  ;  amyloid  degeneration;  hyper- 
trophic cirrhosis;  Banti's  disease. 

2.  Displaced,    in    congenital    dislocation;    rachitis;    right    extensive 

pleural  effusions. 


EXAMINATION    OF    THE   PATIENT 


149 


The  spleen  lies  in  close  contact  with  the  diaphragm,  and  extends 
from  the  left  midaxillary  line  to  a  point  near  the  left  border  of  the 
spinal  column.  Its  upper  border  follows  the  ninth  rib,  its  lower  bor- 
der the  eleventh  rib,  for  the  most  part  bounding  the  left  kidney. 
Normally  the  spleen  cannot  be  outlined  by  percussion,  but  during 
deep  inspiration  it  can  sometimes  be  palpated  at  the  free  borders  of 
the  tenth  and  eleventh  ribs. 


Fig.  24. — Topography  of  the  liver  and  spleen. 

The  spleen  is — 

1.  Enlarged,     primarily,     in    leukemia,    pseudoleukemia;     in    von 

Jaksch's  anemia;  splenitis;  splenomegaly  (Gaucher);  Banti's 
disease;  tumors;  secondarily,  in  malaria;  all  septic  processes; 
tuberculosis;  typhoid;  rachitis;  syphilis;  liver  disease. 

2.  Displaced,  in  pleural  effusions;  deformities  of  chest;  after  severe 

coughing  (pertussis). 
The  kidneys  are  situated  upon  the  right  and  left  sides  of  the  spinal 
column,   and   extend  from  the   levels   of  the   twelfth   dorsal   to   the 
second  lumbar  vertebrae.     The  uppermost  end  of  the  right  kidney 


150 


DISEASES   OF    CHILDREN 


(the  suprarenal  capsule)  is  slightly  overlapped  by  the  liver;  that  of 
the  left  kidney  by  the  spleen.  Normal  kidneys  are  usually  palpable 
when  the  abdomen  is  relaxed,  but  can  never  be  outlined  by  percussion. 
The  urinary  bladder  is  situated  underneath  the  symphysis  pubis,  but 
when  fully  distended  rises  above  it,  eliciting  dull  percussion  resonance. 
Abnormal  size  and  shape  of  the  abdomen — 

1.  Large  and  uniform,  in  flatulence ;  in  acute  and  chronic  gastro- 
enteritis; acute  peritonitis  from  various  causes;  late  stage  of 
grave  pneumonia ;  intestinal  atony  or  paralysis ;  extensive  ascites. 


Fig.  25. — Topography  of  kidneys,  spleen,  and  liver.  S.  Spleen.  L.  Liver.  K.  Kidneys. 


2.  Retracted,  in  collapse,  especially  from  gastrointestinal  disease;  in 
inanition  (pyloric  or  esophageal  stenosis)  ;  meningitis  ("sca- 
phoid abdomen");  general  cachexia  and  loss  of  fat  and  muscle. 
Increased  abdominal  resistance — 

1.  Local,  in  localized  affections  of  the  different  abdominal  organs 
(tumors,  abscesses,  foreign  bodies,  e.g.,  fecal  impaction;  hel- 
minthiasis) . 


EXAMINATION   OF    THE   PATIENT  151 

2.  General,   in   hj^peresthesia ;   rheumatism    of   abdominal   muscles; 
colic;  peritonitis  from  different  causes;  appendicitis;  sclerema; 
scleredema;  extensive  dropsical  effusion. 
Abdominal  pain — 

In  all  conditions  enumerated  under  ''abdominal  resistance,"  except 
sclerema;  scleredema,  and  dropsy.  In  pneumonia,  pleurisj'^ 
(reflex)  ;  in  cholelithiasis;  gastralgia;  ulcer;  nephrolithiasis;  cysti- 
tis ;  vesical  calculi ;  intestinal  adhesions ;  ren  mobilis ;  uterine  and 
ovarian  diseases  (in  older  girls);  in  hysteria. 

Visible  intestinal  peristalsis — 

1.  Normal,  in  very  thin  and  lax  abdominal  parietes,  e.  g.,  congenital 

diastasis  recti  abdominis  (Fig,  37)  ;  infantile  athrepsia;  atrophy 
due  to  paralysis. 

2.  Abnormal  (increased  or  reversed),  in  pylorus  stenosis;  intestinal 

obstruction  or  constriction  from  various  causes;  congenital  dila- 
tation of  the  colon. 
Palpable  or  visible  hemiae — 

1.  In  the  linea  alba  (ventral;  diastasis  recti  abdominis). 

2.  At  the  umbilicus  (congenital  hernia  of  the  cord,  ectopia  viscerum ; 

simple  umbilical  hernia). 

3.  In  the  lumbar  triangles   (lumbar  hernia;  lateral  ventral  hernia). 

4.  In  the  inguinal  regions  (direct  and  oblique  inguinal  hernia). 

5.  At  the  femoral  fossa  (femoral  or  crural  hernia). 

The  Diagnostic  Significance  of  Chronic  Abdominal  Enlargement 

Chronic  abdominal  enlargement  in  children  is  of  common  occurrence 
and  in  the  majority  of  instances  is  due  to  rachitis  and  protracted  in- 
testinal indigestion.  Occasionally,  however,  it  is  the  result  of  certain 
grave  intraabdominal  pathologic  conditions. 

The  liver,  occupying  as  it  does  a  wide  area  of  the  upper  abdominal  cav- 
ity (see  Fig.  23),  is  very  prone  to  cause  considerable  abdominal  enlarge- 
ment even  when  slightly  exceeding  its  normal  boundaries,  as  in  slight 
downward  displacement  or  enlargement.  Displacement  of  the  liver, 
which,  by  the  way  is  often  mistaken  for  enlargement,  is  usually  the 
result  of  rachitic  deformity  of  the  chest,  but  may  occasionally  be 
met  with  in  consequence  of  large  pleuritic  effusions,  emphysema, 
and  pneumothorax.  In  rachitic  displacement  the  diagnosis  can 
readily  be  made  by  percussion,  when  it  is  found  that  the  liver  dul- 
ness,  instead  of  beginning  on  a  level  with  the  sixth  rib,  starts  any- 
where below  this  upper  normal  boundary.  The  same  holds  true 
with    displacement    accompanying     emphysema     or    pneumothorax. 


152     "^0     \   ^1    A  fill.  ^  DISEASES   OF    CHILDREN 


ere  we  have  m  adaiiloh  the  clinical  signs  of  these  affections  to 


go  by,  especially  barrel-shaped  chest  and  exaggerated  resonance  on 
percussion  in  the  former,  and  the  acute  onset  and  tympanitic  percus- 
sion sounds  in  the  latter.  The  diagnosis  of  hepatic  displacement  sec- 
ondary to  pleurisy  with  effusion  is  often  difficult,  owing  to  the  diffi- 
culty of  distinguishing  the  dulness  of  the  liver  from  that  of  the  pleu- 
ritic effusion,  but  the  diagnosis  can  ordinarily  be  cleared  up  by  ex- 
ploratory puncture.  Enlargement  of  the  liver  sufficient  to  produce 
marked  abdominal  enlargement  is  usually  observed  in  connection 
with  syphilis,  neoplasm,  abscess,  hepatic  cyst,  and  congenital  ob- 
literation of  the  bile  duct,  or  secondary  to  pronounced  heart  or 
spleen  affections.  In  older  children  we  must  think  also  of  peri- 
carditic  pseudocirrhosis  of  the  liver  (Pick's  disease),  which  is  asso- 
ciated with  rheumatic  or  tuberculous  obliteration  of  the  pericardium 
and  is  manifested  by  enlargement  of  the  spleen  and  liver  and  by  as- 
cites. In  older  children  also  we  occasionally  meet  with  abdominal  en- 
largement due  to  ascites  associated  with  hypertrophic  and  atrophic 
cirrhosis  of  the  liver  owing  to  abuse  of  alcoholic  beverages. 

Occasionally  a  phantom  tumor  (localized  meteorism  and  contraction 
of  the  intestinal  muscles;  usually  of  a  hysterical  nature)  in  the  epi- 
gastrium, may  be  mistaken  for  a  large  liver.  The  tumor  gives  a  tym- 
panitic note;  ther6  is  no  fluctuation;  it  disappears  under  anesthesia. 

In  examining  the  spleen  we  should  bear  in  mind  that  any  spleen 
that  is  palpable  is  either  diseased  or  displaced.  The  displacement 
may  be  either  congenital,  the  so-called  ** wandering  spleen,"  or  ac- 
quired as  a  result  of  prolonged  and  severe  coughing,  e.  g.,  in  pertus- 
sis. A  displaced  spleen  is  rarely  the  cause  of  marked  abdominal  en- 
largement, and  the  same  is  true  of  a  slightly  enlarged  spleen,  unless 
it  be  associated  with  rachitis.  The  spleens,  large  enough  independ- 
ently greatly  to  influence  the  abdominal  contour  of  children,  are  or- 
dinarily encountered  with  anemia  pseudoleukemica  infantum,  leuke- 
mia, syphilis,  neoplasms  or  primary  splenohepatomegaly  (Gaucher)  (see 
Fig.  158),  more  especially  with  the  latter  affection.  Finally,  on  very  rare 
occasions  abdominal  enlargement  is  found  to  be  due  to  so-called  Banti's 
disease,  which  is  characterized  by  splenomegaly,  anemia,  cirrhosis  of 
the  liver,  ascites,  and  hemorrhages. 

The  usual  kidney  affections  are  not  productive  of  abdominal  en- 
largement except  in  their  late  stages  as  a  result  of  dropsical  effu- 
sions within  the  abdominal  cavity,  or  of  secondary  involvement  of  other 
organs.  In  such  cases  the  diagnosis  is  obvious.  As  we  palpate  the 
kidneys,  which  procedure  is  readily  accomplished  especially  when 
they  are  displaced  or  enlarged,  we  should  be  watchful  for  hydroneph- 


EXAMIXATIOX    OF    THE    PATIENT 


153 


rosis  and  neoplasms.  Hydronephrosis,  in  order  materially  to  change 
the  outline  of  the  child's  abdomen,  is  usually  large  enough  readily  to 
be  felt  as  an  immovable,  fluctuating  mass  in  the  lumbar  region,  but 
considerable  difficulty  is  experienced  in  differentiating  unilateral  hy- 
dronephrosis from  a  cystic  tumor  of  the  kidney.  As  hydronephrosis  is 
due  either  to  congenital  atresia  or  acquired  occlusion  of  the  ureter,  its 
differentiation  from  cystic  kidney  can  be  made  only  by  a  careful  ure- 
teroscopic  examination  or  puncture  of  the  mass  (showing  the  pres- 


Fig.  26. — Sarcoma  of  the  left  kidney. 


ence  of  urine)  through  the  abdominal  wall.  Ordinarily  one  would 
rarely  err  in  diagnosing  a  kidney  neoplasm  rather  than  hydronephro- 
sis, since  the  former  is  by  far  more  common  than  the  latter.  This 
is  true,  especially  of  sarcoma.  Hard  tumors  of  the  kidney  are  best 
diagnosed  by  palpation,  if  need  be  under  anesthesia,  although  some 
diagnostic  help  is  also  obtained  from  the  x-rays.  No  great  reliance 
should  be  placed  upon  hematuria  as  a  characteristiQ  sign  of  renal 


154 


DISEASES   OP    CHILDREN 


neoplasm,  since  blood  in  the  urine  is  frequently  found  in  renal 
tuberculosis,  hemorrhagic  nephritis,  purpura,  and  other  diseased  con- 
ditions, and  is  often  absent  in  kidney  tumors  when  large  enough  to 
obstruct  the  ureter  so  that  no  urine  is  excreted  from  the  affected  side. 
Next  to  rachitis,  tuberculosis  of  the  peritoneum  or  intestines  forms 
the  most  frequent  cause  of  abdominal  enlargement  in  children.  But 
while  we  meet  these  cases  almost  daily  in  hospital,  dispensary,  and 
private  practice,  the  diagnosis  is  not  always  easy.  It  is  often  espe- 
cially difficult  to  detect  tuberculosis  of  the  intestines.  The  tubercu- 
lous lesions  are  usually  located  in  the  lower  portions  of  the  ileum. 


Fig.  27, — High  degree  of  rachitis.  Abdominal  enlargement  chiefly  in  epigastric  region. 


ileocecal  region,  and  colon,  but  owing  to  the  accompanying  intense 
meteorism,  the  intestinal  tumefaction  is  beyond  reach  of  palpation,  par- 
ticularly during  the  early  stages.  However,  as  the  diagnosis  can  fre- 
quently be  established  by  the  demonstration  of  tubercle  bacilli  in  the 
stools,  these  should  always  be  subjected  to  minute  bacteriologic  ex- 
amination whenever  stubborn  diarrhea  and  rapid  emaciation  prevail. 
Less  difficulty,  as  a  rule,  is  experienced  in  the  diagnosis  of  tuberculous 
peritonitis,  because  the  tuberculous  peritoneal  masses  are  more  super- 
ficial and  hence  more  readily  palpable,  and  also  because  of  the  pres- 


EXAMINATION    OF    THE   PATIENT 


155 


ence  of  fluid  in  the  abdominal  cavity.  A  positive  tuberculin  reaction, 
of  course,  is  corroborative  of  the  diagnosis.  It  should  be  borne  in  mind, 
however,  that  a  negative  result  by  no  means  proves  the  absence  of  tu- 
berculosis. This  point  is  deserving  of  special  emphasis.  I  desire  to 
call  particular  attention  to  a  physical  sign  which  proved  to  me  very 
helpful  in  differentiating  abdominal  enlargement  associated  with  rachi- 
tis from  that  of  tuberculous  peritonitis.  Whereas  in  rachitis  (Fig. 
27)  the  greatest  prominence  of  the  abdomen  is  manifested  at  the 
epigastrium,  in  tuberculous  peritonitis  (Fig.  28)  the  abdominal  cir- 
cumference is  largest  at  or  below  the  umbilicus  (hypogastrium).  This 
differential  physical  sign  can  best  be  elicited  by  careful  measurements 


Fig.  28. — Tuberculous  peritonitis.    Abdominal  enlargement  most  marked  iu  hypogas- 
tric region. 

of  the  abdominal  circumference  by  means  of  a  tape  measure,  but  can 
readily  be  determined  also  by  mere  inspection.  This  sign  can  be  ex- 
plained by  the  fact  that  in  tuberculous  peritonitis  the  inflammatory 
exudate  accumulates  at  the  bottom  of  the  abdominal  cavity  and  thus 
distends  the  surrounding  abdominal  wall.  To  make  correct  use,  how- 
ever, of  this  sign  we  must  be  sure  to  exclude  large  dermoid  cysts 
of  the  ovary  and  an  overdistended  bladder,  both  of  which  conditions 
are  apt  to  lead  to  diagnostic  errors. 

There  is  one  other  intestinal  abnormality  which  often  gives  rise  to 
an  enormous  abdominal  enlargement  in  children,  and  that  is,  congenital 
or  acquired  hypertrophy  and  dilatation  of  the  colon,  the  so-called  Hirsch- 


156  DISEASES   OF    CHILDREN 

sprung's  disease  (see  Fig.  34).  While  it  was  originally  thought  to  be 
a  congenital  affection  only,  it  has  lately  been  shown  to  develop  grad- 
ually also  after  birth.  In  these  cases  particularly  the  diagnosis  is 
often  very  difficult,  but  nowadays,  with  the  help  of  the  x-ray,  the  diag- 
nosis can  readily  be  made,  even  if  the  usual  symptoms  of  the  disease 
fail  to  disclose  the  pathologic  condition. 

Vomiting — 

1.  Gastroenteric  (associated  with  nausea  and  effort;  followed  by  re- 

lief), in  simple  gastroenteric  disturbances  and  intoxication; 
pyloric  stenosis  or  spasm;  acidosis;  intestinal  obstructon  from 
various  causes ;  appendicitis ;  peritonitis ;  the  effect  of  emetics 
or  poisonous  drugs  (taken  by  mouth). 

2.  Cerebral  (explosive;  w^atery,  recurrent  without  relief). 

(a)  Direct,  in  acute  and  chronic  affections  of  the  cerebrospinal 
system ;  shock ;  psychic  emotion. 

(6)  Reflex,  in  extracranial  irritation  of  the  cranial  nerves,  e.g., 
of  the  optic  or  oculomotor  nerves  in  visual  defects ;  of  the 
auditory  nerve,  in  otitides;  pneumogastric,  in  pulmonary  and 
cardiac  diseases.  Also  in  toxemia,  by  bacterial  or  chemical 
products  (e.g.,  sepsis,  uremia,  etc.).  To  the  latter  group  be- 
longs the  vomiting  accompanying  migraine. 

Vomitus — 

1.  Mucous,  in  chronic  catarrh  of  the  stomach ;  after  swallowing  large 

quantities  of  expectoration,  in  nasopharyngeal  and  laryngeal 
inflammation  or  pertussis. 

2.  Bilious  (yellowish-green  or  green),  in  gastroenteric  disturbances  af- 

ter repeated  vomiting ;  in  peritonitis ;  intestinal  obstruction ;  liver 
affections;  in  the  late  stages  of  acidosis. 

3.  Bloody  (hematemesis),  in  hemophilia  and  melena  neonatorum;  con- 

genital obliteration  of  the  bile  ducts;  cirrhosis  of  the  liver;  ul- 
ceration of  the  lining  of  alimentary  tract,  especially  of  the 
upper  part  (from  corrosive  poisons;  syphilis,  etc.)  ;  in  vicarious 
menstruation. 

4.  Purulent,  in  rupture  into  the  stomach  of  large  abscesses  in  the 

adjacent  organs  (e.g.,  empyema). 

5.  Fecal,   in  severe   intestinal   obstruction   with   reversed   peristalsis 

(e.g.,  intussusception). 

6.  Parasitic,  in  helminthiasis;  anchylostomiasis ;  trichiniasis ;  echino- 

coccosis. 


EXAMINATION    OF    THE   PATIENT  157 

Diarrhea.* — One  to  two  movements  in  twenty-four  hours  are  looked 
upon  as  normal.  But  even  double  the  number  of  evacuations  is 
not  necessarily  a  manifestation  of  a  pathologic  condition  unless 
the  consistency,  color  and  odor  of  the  stools  are  materially  al- 
tered. Since  on  the  first  visit  a  specimen  of  the  stool  is  not  al- 
ways obtainable,  and  even  if  obtained  is  not  invariably  of  the 
same  consistence  as  the  preceding  movements,  it  is  important  to 
gather  all  the  information  possible  as  to  the  abnormality  in  ques- 
tion— number,  time  of  occurrence,  quantity  and  quality. 

1.  Acute  diarrhea  occurs  after  the  administration  of  cathartics 

or  corrosives;  in  indigestion;  stomatitis;  gastroenterocolitis; 
proctitis  and  dysentery-  (blood,  mucus  and  often  pus)  ;  acute 
peritonitis;  during  the  course  of  divers  infectious  diseases, 
especially  cholera,  typhoid,  scarlatina,  measles,  influenza,  sep- 
sis, etc. 

2.  Chronic  diarrhea  is  observed  in  dyspepsia;  chronic  gastroen- 

terocolitis; chronic  proctitis  and  dysentery  (amebicj  ;  intes- 
tinal  tuberculosis   and   other   chronic   Avasting   diseases    (es- 
pecially syphilis,  leukemia,  amyloidosis)  ;  helminthiasis  (espe- 
cially in  triehocephalus  and  ankylostomum — often  mucosan- 
guinolent  stools)  ;  malaria  (periodic)  ;  intestinal  lithiasis  (mu- 
cus, blood  and  sand),  and  in  partial  intestinal  stenosis  (band- 
like, flat,  mixed  with  mucus). 
Constipation.* — In    determining    the    clinical    significance    of    consti- 
pation, inquiry  should  be  made  as  regards  the  duration  of  the 
constipation,  mode  of  feeding  the  child,   presence  or  absence   of 
vomiting  and  tenesmus,  and  the  color  and  consistency  of  the  stools. 

1.  Habitual  constipation  occurs  in  consequence  of  insufficient  (py- 

loric stenosis)  or  improper  feeding  (excess  of  fat  or  starches, 
etc.);  intestinal  atony  (from  a  great  number  of  causes,  e.g., 
congenital  or  acquired  muscular  insufficiency — megacolon,  or 
artificial  distention),  general  debility,  cretinism,  etc.;  partial 
intestinal  obstruction  (e.  g.,  hernia,  neoplasms)  and  abstinence 
owing  to  painful  lesions  in  the  rectum  (e.  g.,  hemorrhoids,  fis- 
sures). 

2.  Acute  constipation,  with  persistent  vomiting,  pain,  meteorism, 

etc.,  in  all  forms  of  congenital  intestinal  atresia  and  acquired 
acute  intestinal  obstruction  (intussusception,  strangulation, 
fecal  impaction,  peritonitis,  appendicitis,  and  volvulus). 


*See  "Infants'   Stools,"   p.   158;  ^Iso  "Infant   Feeding,"   p.   55. 


158  DISEASES   OF    CHILDREN 

INFANTS'  STOOLS 

The  character  (consistency,  color,  reaction,  odor,  etc.)   of  infants' 
stools  greatly  depends  upon  the  kind  and  quantity  of  food  consumed. 

Normal  stools — 

1.  Soft  and  pasty,  golden  yellow,  slightly  acid  and  almost  odorless, 

in  breast-milk  feeding. 

2.  Soft,  putty-like,  whitish-yellow,  slightly  alkaline  and  slightly 

offensive  in  odor,  in  cow's  milk  feeding. 

3.  Soft,   salve-like,   yellowish-brown  or   brown,   slightly   alkaline 

or  neutral,  and  malt-like  in  odor,  in  feeding  with  malted  or 
farinaceous  foods. 

Abnormal  stools — 

(a)   Consistency — 

1.  Soft,  smeary,  like  moistened  shavings  of  soap,  or  grayish 

yellow,  hard  and  dry  "soap  stools,"  in  fat  indigestion. 
•2.  Soft  or  hard  and  mixed  with  tough  white  curds,  in  casein 
indigestion;  hard,  lumpy,  in  habitual  constipation. 

3.  Loose,  brown  stools  mixed  with  mucus  in  starch  indigestion. 

4.  Thin,    yellowish    green    in    gastroenteritis ;    typhoid    fever ; 

from  the  effects  of  hydragogue  cathartics;  rectal  stricture 
{e.g.,  syphilitic). 

5.  Serous,  in  severe  gastroenterocolitis ;  cholera. 

6.  Mucous,  in  obstinate  constipation  with  tenesmus;  in  disease 

of  the  large  intestine   (colitis,  large  quantity)  ;  in  disease 
of  the  small  intestine  (mixed  with  feces). 

7.  Bloody,    in   rectal   affections    {e.g.,   proctitis,    hemorrhoids, 

foreign   bodies,   fissure,    polypus,    prolapsus);   dysentery; 
intussusception;  hemorrhagic  diseases   {e.g.,  melena,  pur- 
pura, hemophilia). 
(&)   Color— 

1.  Yellowish-green,  in  gastrointestinal  indigestion    (especially 

of  casein). 

2.  Green,  in  gastroenteritis;  excess  of  sugar;  from  the  effects 

of  calomel. 

3.  Clay-color,  in  obstruction  to  the  flow  of  bile. 

4.  Black,  in  meconium;  from  the  effects  of  iron,  manganese 

and  bismuth;  also  from  blood  (coming  from  upper  portion 
of  the  bowels). 

5.  Red,  from  admixture  of  blood  (from  lower  portion  of  bowels, 

especially  rectum). 


EXAMINATION    OF    THE   PATIENT  159 

(c)  Reaction — 

1.  Decidedly  alkaline,  in  protein  indigestion. 

2.  Moderately  acid,  in  fat  indigestion  (from  fatty  acids)  ;  car- 

bohydrate indigestion  (acetic  or  lactic  acid). 

3.  Strongly  acid,  in  sugar  indigestion. 
{d)   Odor— 

1.  Foul,  in  protein  indigestion. 

2.  Rancid,  in  fat  indigestion. 

3.  Sour  or  pungent,  in  carbohydrate  indigestion. 

The  stools  should  be  examined  also  for  parasites  (see  "Intestinal 
Worms,"  p.  276)  and  calculi. 

(e)  Bacterial  flora — 

1.  In  breast-fed  feces:     B.  bifidus  communis;  B.  acidophilus; 

few  coli ;  and  B.  lactis  aerogenes. 

2.  In  cow's  milk  fed  feces:    B.  coli  communis  (splits  milk  sugar 

in  lactic  acid,  carbonic  acid  and  water,  and  partly  splits 
fat  in  fatty  acids)  and  with  it  in  varying  number  B.  acid- 
ophilus, micrococcus  ovalis;  enterococcus  (Thiarceli), 
Gram-staining  diplococcus,  strepto-  and  staphylococci,  sar- 
cinsB  and  B.  lactus  aerogenes  (splits  milk  sugar  into  lactic 
acid,  carbonic  acid  and  water,  causing  the  intestinal  con- 
tents to  become  acid). 

Principal  Abnormalities  of  Urine 

In  male  infants  the  urine  may  be  collected  by  placing  the  penis  in 
a  test  tube  or  the  neck  of  a  bottle,  fastened  by  means  of  strips  of 
adhesive  plaster;  in  female  infants,  by  placing  absorbent  cotton  in 
front  of  the  vulva,  or  placing  the  buttocks  on  a  flat  bed  pan.  Where 
these  measures  fail,  catheterization  should  be  resorted  to. 

Traces  of  albumin  and  sugar ;  occasionally  hyaline  and  granular 
casts;  a  moderate  amount  of  mucus,  uric  acid  crystals,  and  urea,  are 
found  in  the  urine  of  healthy  infants  in  the  first  few  weeks  of  life. 

The  quantity  of  urine  passed  in  twenty-four  hours  is  larger  in  infants 
than  in  older  children,  but  varies  with  the  amount  of  liquid  con- 
sumed.   It  is  smaller  in  breast-fed  than  in  bottle-fed  babies. 

Polyuria  in — 

1.  Diabetes  mellitus. 

2.  Diabetes   insipidus. 

3.  Contracted  kidney. 

4.  Granular  atrophy  of  the  kidney. 

5.  Amyloid  kidney. 


160  DISEASES   OF    CHILDREN 

6.  Convalescence   after  acute   diseases    (epicritic  polyuria). 

7.  Disease  of  the  nervous  system,  functional  and  organic,  as  hys- 

teria, neurasthenia,  migraine,  chorea,  epilepsy,  tabes,  cerebro- 
spinal meningitis. 

8.  Medicinal  (acetates,  salicylates,  digitalis,  calomel,  etc.). 

Oliguria  in— 

1.  Febrile  conditions. 

2.  Profuse  diarrhea. 

3.  Circulatory  disturbances. 

4.  Acute  nephritis. 

5.  Some  forms   of   chronic   nephritis. 

Anuria  in — 

1.  Atresia  urethras,  in  the  newborn. 

2.  Uremia. 

3.  Acute  anemia  (after  severe  hemorrhage). 

4.  Catarrh  of  the  stomach  or  intestines. 

5.  Cholera. 

6.  Dysentery. 

7.  Nervous  manifestations. 

8.  Lead  colic. 

9.  Poisoning  with  arsenic,   corrosive   sublimate,   morphine,   atro- 

pine, oxalic  acid,  etc. 

Glycosuria — 

(a)   Constant,  in  diabetes  mellitus. 
(6)   Transient  in — 

1.  Cholera, 

2.  Typhoid  fever. 

3.  Intermittent  fever,  particularly  during  convalescence. 

4.  Syphilis. 

5.  Scarlatina. 

6.  Measles. 

7.  Diphtheria. 

8.  Influenza. 

9.  Gout. 

10.  Disease  of  the  lungs  and  liver. 

11.  Disease  of  the  brain,  involving  the  fourth  ventricle. 

12.  Cerebrospinal  meningitis. 

13.  Tetanus. 

14.  Lesions  affecting  the  central  and  peripheral  nervous  system. 


EXAMINATION    OF    THE   PATIENT  161 

15.  Poisoning  with  morphine,  atropine,  strychnine,  oxalic  acid, 
carbon  monoxide,  lead,  chromates,  chloroform,  ether,  etc. 
(c)   Transient,  alimoitnry  in — 

1.  Disorder  of  the  stomach. 

2.  Overingestion  of  starchy  and  saccharine  foods. 

3.  Cirrhosis  of  the  liver. 

4.  Morbus  Basedowii. 

5.  Disease  of  the  heart. 

6.  Phosphorns  poisoning. 

7.  Atrophy  of  the  liver. 

8.  Traumatic  neuroses. 

9.  Fatty  degeneration  of  the  liver. 
10.  Psoriasis. 

Acetone  in — 

1.  Diabetes  mellitus,  especially  in  advanced  cases;  diabetic  coma. 

2.  Acidosis. 

3.  Fever;  inanition. 

4.  Carcinoma. 

5.  Autointoxication. 

6.  Psychoses. 

7.  After  chloroform  narcosis. 

Diacetic  acid  in — 

1.  Diabetes  mellitus,  advanced  cases. 

2.  Autointoxication   (diacetonuria)  acidosis. 

Albuminuria — 

(a)  Renal  (nephritis,  pyelitis,  pyelonephritis,  nephrolithiasis). 
(&)   Vesical  (calculi,  colicystitis)  ;  in  tumors. 

(c)  Changes  in  the  constitutio7i  of  the  Mood — 

1.  Ischemia. 

2.  Anemia. 

3.  Struma. 

4.  General  weakness. 

5.  Effect  of  certain  poisons,  as  cantharides,  mustard,  oil  of  tur- 

pentine, carbolic  acid,  alcohol,  lead,  etc. 

6.  Infectious  fevers — Microorganisms  in  the  blood. 

7.  Febrile  conditions. 

(d)  Disturbance  in  the  circulation — 

1.  Acceleration  of  the  arterial  current. 

2.  Slowing  of  the  venous  current. 

3.  Prolonged  muscular  exercise. 


162  DISEASES   OP    CHILDREN 

4.  After  cold  baths. 

5.  After  epileptic  fits. 

6.  Compression  of  the  thorax. 

7.  Derangement  of  the  cerebrospinal  system, 
(e)  Fu7ictional — 

Orthotic,  lordotic. 
(/)  Digestive — 

Ingestion  of  excessive  quantities  of  albumin  (e.  g.,  eggs,  cheese, 
raw  beef). 
Casts — 

(a)  Hyaline  (narrow  and  broad),  in 

Acute  and  chronic  nephritis. 
(&)   Granular  (coarse  and  fine  granules),  in 

Chronic  pathologic  conditions  of  the  kidney. 

(c)  Epithelial,  in 

Inflammation  in  the  anatomical  structure. 

(d)  Bloody,  in 

1.  Hematuria. 

2.  Acute  diffuse  nephritis. 

3.  Acute  renal  congestion. 

4.  Hemorrhagic  infarction  of  the  kidney. 

(e)  Fatty,  in 

Fatty  changes  in  the  kidney,  large  white  kidney. 
(/)   Waxy,  in 

Amyloid  kidney  and  many  forms  of  nephritis. 
(g)  Bacterial,  in 

Interstitial  suppurative  nephritis,  ascending  pyelonephritis. 
(/?)  Purulent,  in 

Abscess  of  the  kidney. 

Uric   acid   (pathologic,   when   deposit  occurs   shortly   after   urine   is 
voided)  in — 

1.  Acute  fevers. 

2.  Increased  tissue  metabolism. 

3.  Defective  physiologic  action  of  the  liver. 

4.  Sedentary  habits  of  life. 

5.  Early  stages  of  interstitial  nephritis. 

6.  Convalescence  from  scarlatina,  etc. 

Hematuria  (blood) — 
(a)  Renal,  in 

1.  Bright 's  disease. 

2.  Amyloid  disease. 


EXAMINATION    OF    THE    PATIENT  163 

3.  Malignant  growths. 

4.  Tnberculosis. 

5.  Renal  calculi. 

6.  Cystic  disease  of  the  kidney. 

7.  Abscess. 

8.  Renal  embolism. 

9.  Hydatids. 

10.  Acute  febrile  processes. 

11.  Purpura  hemorrhagica. 

12.  Traumatism  involving  the  kidney. 

13.  Ingestion    of    medicines,    such    as   turpentine,    cantharides, 
arsenic,  etc. 

(&)   Vesical,  in 

1.  Stone  in  the  bladder. 

2.  Cystitis. 

3.  Neoplasms  of  the  bladder, 
(c)    Urethral,  in 

1.  Foreign  bodies. 

2.  Acute  gonorrhea. 

3.  Neoplasms. 

4.  Traumatism. 
Pyuria  (pus)  — 

(a)  Renal,  in 

1.  Pyelonephritis. 

2.  Pyelitis. 

3.  Cancer. 

4.  Tuberculosis. 

5.  Nephritic  abscess, 
(6)   Vesical,  in 

1.  Cystitis  (colicystitis). 

2.  Vesical  stone. 

3.  Ulceration. 

4.  Tuberculosis, 
(c)   Urethral,  in 

1.  Gonorrhea. 

2.  Urethritis. 

3.  Rupture  of  abscess  in  urinary  passages. 

Peptonuria,  in — 

1.  Croupous  pneumonia. 

2.  Bronchopneumonia. 

3.  Empyema. 

4.  Phthisis  pulmonum. 


164  DISEASES   OF    CHILDREN 

5.  Epidemic  cerebrospinal  meningitis. 

6.  Typhoid  fever. 

7.  Scarlet  fever. 

8.  Malaria. 

9.  Erysipelas. 

10.  Purpura  hemorrhagica — diverse  forms. 

11.  Scurvy. 

Bacteriuria  (pathogenic)  is  the  result  of  infection  by  the 

1.  Gonococcus. 

2.  Tubercle  bacillus. 

3.  Colon  bacillus. 

4.  Strepto-  or  staphylococcus. 

Parasituria — 

1.  Distomum  hematobium. 

2.  Filiaria. 

3.  Hooklets  of  echinococcus. 

THE  GENITALIA 

In  the  male  child  we  should  look  for  abnormalities  of  the  penis 
(malformations,  adhesions  of  the  prepuce,  phimosis,  overstretched 
prepuce  from  masturbation,  faulty  location  of  the  urethral  orifice, 
urethral  discharge),  scrotum  and  its  contents  (tumefactions,  unde- 
scended testicles). 

Scrotal  tumefactions — 

1.  Communicating  with  abdominal  cavity,  in  hernia;  hydrocele; 

and,  higher  up  in  the  inguinal  canal,  partly  descended  testicle. 

2.  Noncommunicating  with  abdominal  wall,  in  orchitis  (occasion- 

ally with  parotitis),  epididymitis,  syphilis,  tuberculosis,  cysts, 
and  malignant  growths  of  testicle. 

3.  Dropsical  effusions,  of  renal  or  cardiac  origin  or  edema  from 

circulatory  disturbance  in  the  spermatic  cord. 

4.  Local  scrotal  inflammation,  in  abscess,   erysipelas,   gangrene ; 

sebaceous  cysts ;  traumatism. 
In  the  female  we  should  note  the  presence  of  labial  hernia  or  hema- 
toma, vaginal  discharge  or  deposits   (in  diphtheria  and  noma)  ;  en- 
larged clitoris  or  preputial  adhesions;  atresia  vaginae;  abnormalities 
of  the  hymen  (imperforate). 

Vulvovaginal  discharge — 

1.  Mucous,  white,   in  simple  catarrhal  vulvovaginitis    (from  lack 
of  cleanliness;  irritating  urine). 


EXAMINATION    OF    THE    PATIENT  165 

2.  Purulent,  yellow,  or  yellowish-green,  in  gonorrheal  vulvovagi- 

nitis or  infection  by  other  microorganisms  {e.g.,  streptococcus 
in  exanthematous  diseases)  ;  cervicitis. 

3,  Hemorrhagic,  in  hemorrhagic  diathesis   (in  the  newborn  and  in 

older  children)  ;  in  vulvovaginitis  with  erosions  of  the  mucous 
membrane  (sometimes  after  severe  local  treatment)  ;  prolapse 
of  the  urethra ;  neoplasms ;  menstruatio  precox. 

THE  RECTUM 

Abnormalities  of  the  rectum  can  readily  be  detected  by  inspection 
(sometimes  Avith  the  aid  of  proctoscope)  and  digital  examination. 
We  should  look  for  condylomata,  fistulffi,  prolapsus,  hemorrhoids, 
polyps,  prolapse  of  intussuscepted  intestine,  fissures,  pinworms,  for- 
eign bodies  and  discharges. 

Rectal  discharg-es — 

1.  Mucous,  mucopurulent,  and  slightly  bloody,  in  simple  procti- 

tis ;  rectal  fissure  or  fistula ;  colitis. 

2.  Purulent,   in   communicating   ischiorectal   abscess;    gonorrheal 

proctitis;  impacted  foreign  body. 

3.  Hemorrhagic,   in  hemorrhoids;   polyps;   dysentery;   ulcerative 

proctitis  (tuberculous,  or  otherwise);  intussusception;  pro- 
lapsus recti;  hemorrhagic  diathesis. 

THE  VERTEBRAL  COLUMN 

The  vertebral  column  of  the  infant  under  six  months  is  quite 
straight,  except  for  a  slight  dorsal  curve.  As  the  child  grows  older 
and  attains  the  power  of  sitting,  standing  and  walking,  we  soon  find  the 
dorsal  region  of  the  spinal  column  curving  posteriorly  and  the  cervical 
and  lumbar  regions  anteriorly — compensatory  curvatures.  At  first 
these  curves  disappear  in  the  recumbent  posture,  but  they  become  per- 
manent at  about  the  age  of  six.  The  normal  spinal  column  is  per- 
fectly movable. 

In  the  physical  examination  of  the  spinal  column  we  note  the  pres- 
ence of: 
Deformities  (lordosis,  kyphosis  and  scoliosis) — 

1.  Congenital,  in  osteogenesis  imperfecta,  etc.;  cervical  rib. 

2.  Habitual,  or  postural  from  faulty  posture;  the  effect  of  super- 

encumbrance  (carrying  of  heavy  weights  upon  the  back  or 
shoulders). 

3.  Static,  the  result  of  oblique  pelvis,  e.  g.,  congenital  or  acquired 

shortening  of  one  lower  extremity  as  in  hip- joint  disease. 


166  DISEASES   OP    CHILDREN 

4.  Tuberculous,  in  vertebral  caries. 

5.  Neuromuscular,  in  muscular  insufficiency  (to  which  belongs  also 

rachitic  deformity  of  the  spine),  or  paralysis,  e.g.,  poliomyeli- 
tis ;  pseudoparalysis. 

6.  Clefts,  usually  congenital,  e.  g.,  spina  bifida. 

Tumors — 

1.  Congenital,  teratomas;  hernial  protrusions. 

2.  Acquired,  in  vertebral  caries,  osteoma. 

Stiffness'''  (with  or  without  pain)— 

1.  Central,  in  meningitis;  meningeal  irritation  {e.g.,  apex  pneu- 

monia; hydrocephaloid)  ;  encephalitis. 

2.  Spinal,  in  disease  of  the  spinal  cord    {e.  g.,  spinal  meningitis, 

myelitis)  ;  in  trauma  or  disease  of  the  vertebrte  or  articulation 
{e.g.,  vertebral  caries,  spondylarthritis).  Also  cervical  rib; 
osteoma. 

3.  Neuromuscular,  in  neuralgia;  myalgia;  myositis. 

THE  EXTREMITIES 

The  extremities  should  be  examined  with  a  great  deal  of  care — in- 
spected, measured,  palpated,  percussed — since  their  anomalies  in  form 
and  disturbances  in  function,  etc.,  furnish  most  instructive  informa- 
tion not  only  as  to  the  existence  of  local  disease,  but  also  as  to  gen- 
eral systemic  affections,  preeminently  those  of  the  nervous  system. 

Shortness  of — 

1.  Single  limbs,  in  paralytic,  hysterical  or  traumatic    {e.g.,  after 

fracture)  contractures;  hip- joint  disease;  congenital  deformi- 
ties; septic  processes. 

2.  All  extremities,  in  achondroplasia   (as  compared  with  the  long 

trunk).  , 

Curvatures — 

1.  Congenital,  in  divers  congenital  malformations  (e.  g.,  osteogen- 

esis imperfecta;  osteomalacia;  achondroplasia). 

2.  Acquired,  after  fractures;  in  syphilis;  rachitis;  tuberculosis. 

Tumefactions — 

1.  Diaphyseal,  tuberculous  and  nontuberculous,  in  periostitis; 
osteitis;  osteomyelitis;  syphilis;  exostosis;  malignant  growths; 
after  fracture. 


•See  also   "Attitude   of  the   Head   and   Neck,"   and   "'Spondylitis." 


EXAMINATION    OF    THE    PATIENT  167 

2.  Epiphyseal,  the  same  as  in  diaphyseal,  also  in  rachitis ;  Bar- 
low's  disease;  arthritis  deformans;  rheumatic  affections;  sep- 
tic arthritides;  hemarthrosis  (hemophilia,  peliosis  rheumatica)  ; 
synovitis;    bursitis;    "intermittent    hydrops." 

Muscular  Weakness,  "flaccidity"  (with  or  without  atrophy) — • 

1.  Without  true  paralysis,  in  pseudoparalysis  of  syphilitic  oriu^in 

(upper  extremities)  ;  Barlow's  disease;  amyatonia ;  osteomye- 
litis; osteomalacia;  polyarthritis  and  myositis;  traumatism  of 
the  muscles  or  bones  (dislocation  or  fracture);  progressive 
muscular  atrophies  (muscular  and  neurospinal  types)  ;  idiocy 
(especially  amaurotic  family  idiocy)  and  cretinism;  rachitis 
and  muscular  debility  after  prolonged  sickness  (in  bed) ;  hys- 
teria. 

2.  With   paresis   or   paralysis,   in   poliomyelitis    (early)  ;   myelitis 

(the  muscular  involvement  depending  upon  the  seat  of  the 
lesion  in  the  cord);  Landry's  paralysis;  spinal  meningitis; 
chronic  polyneuritis  (usually  bilateral  and  symmetrical)  from 
various  causes ;  birth  palsies. 

Muscular  Contracture,  "spasticity"  (with  or  without  atrophy)  — 

1.  Without   true   paralysis,   in  trismus   and  tetanus   traumaticus 

and  neonatorum;  meningismus;  early  stage  of  meningitis; 
tetany;  pseudotetany ;  tetanism  (q.v.,);  eclampsia  infantilis; 
myotonia  (Thomsen)  ;  catalepsy;  hysteria;  trichiniasis;  hydro- 
cephaloid. 

2.  With  paresis  or   paralysis,   in   all   forms   of  cerebral  paralysis 

(cerebral  hemorrhage,  embolism,  abscess,  tumor,  sclerosis,  tu- 
berculosis, encephalitis,  porencephalia,  hydro-  or  microcephal- 
ous, etc.)  ;  myelitis  (late  stage)  ;  spastic  spinal  paralysis;  amyo- 
trophic lateral  sclerosis  anterior  poliomyelitis   (late). 

Spasmodic  movements* — 

1.  Intention  tremor,   in   disseminated   sclerosis;   ataxia  heredita- 

ria ;  spastic  cerebral  paralysis ;  myotonia  congenita. 

2.  Irregular  shaking,  in  cerebral  hemorrhage;  tumor,  encephalitis; 

hydrocephalus;  all  forms  of  meningitis;  toxic  neuritis,  espe- 
cially diphtheritic  and  uremic;  hysteria;  Jacksonian  epilepsy; 
idiocy;  torsion  spasm. 

3.  Fibrillary  twitching,  in  progressive  muscular  atrophy;  acute 

febrile  diseases ;  neuroses ;  strychnine  poisoning. 


*See  also  "Convulsions,"  p.  669. 


168  DISEASES   OF    CHILDREN 

4.  Athetoid  movements,  in  chronic  brain  affections,  especially  of 

the  internal  capsule. 

5.  Choreiform  movements,  in  all  forms  of  chorea;  spasmus  nutans; 

spastic  cerebral  paralysis;  paramyoclonus  multiplex;  hysteria; 
tie;  lethargic  encephalitis. 

Paralysis — 

(a)   Unilateral — 

1.  Upper  and  lower,  in  lesions  of  one  cerebral  hemisphere,  e.  g., 

cerebral  hemorrhage,  embolism,  abscess;  tumor,  sclerosis, 
encephalitis,  meningitis,  depressed  fracture,  porencephalia, 
etc. ;  poliomyelitis. 

2.  Upper,  in  unilateral  cerebral  lesion  of  tlie  arm  center  {e.  g., 

embolism,  tubercle,  etc.)  ;  unilateral  spinal  lesion  of  the 
cervical  region  {e.g.,  incipient  spondylitis,  etc.);  trauma- 
tism to  the  brachial  plexus  (e.  g.,  birth  palsy)  ;  poliomyeli- 
tis ;  regressive  stage  after  hemiplegia. 

3.  Lower,  in  unilateral  cerebral  lesion  of  the  leg  center  (same 

as  in  upper)  ;  unilateral  spinal  lesion  in  the  lumbar  region ; 
trauma  of  the  lumbar  plexus;  poliomyelitis. 

(&)  Bilateral — 

1.  Upper  and  lower,  in  bilateral  lesions  of  the  brain   (cortex, 

pons,  or  medulla),  e.g.,  intracranial  hemorrhage,  multiple, 
growths,  especially  tuberculous  and  syphilitic,  disseminated 
sclerosis,  etc. ;  spinal  sclerosis ;  spinal  meningitis ;  polio- 
myelitis; Landry's  paralysis  (late)  ;  progressive  muscular 
atrophy  (late)  ;  amyotrophic  lateral  sclerosis  (late)  ;  syr- 
ingomyelia (late);  multiple  neuritis;  amaurotic  family 
idiocy  (late). 

2.  Upper,  in  double  trauma  of  the  brachial  plexus  or  individual 

cords  {e.g.f  compression  in  instrumental  delivery;  trans- 
verse cervical  myelitis)  ;  poliomyelitis;  Landry's  paralysis 
(early)  ;  bilateral  cerebral  lesions  of  the  arm  centers;  syr- 
ingomyelia (early). 

3.  Lower,  in  bilateral  trauma  of  the  lumbar  plexus  or  its  main 

branches;  transverse  lumbar  myelitis;  transverse  dorsal 
myelitis  (late)  ;  spastic  spinal  paralysis;  hereditary  ataxia 
(late)  ;  tabes  dorsalis  (late)  ;  polyneuritis,  especially  diph- 
theritic (early)  ;  amyotrophic  lateral  sclerosis  (early)  ;  pol- 
iomyelitis; bilateral  cerebral  lesions  of  the  leg  centers; 
hydrocephalus. 


EXAMINATION    OF    THE   PATIENT  169 

Local-zed  paralysis  of  principal  muscles  concerned  in  movements  of 
the  extremities  and  their  nerve  supply — 
(«)    Upper  extremities* — 

1.  Trapezius    (spinal   accessory    nerve) :    Sinking    of    shoulder 

downward  and  forward ;  rotation  of  scapula  outward  and 
upward;  elevation  of  shoulder  imperfect. 

2.  Serratiis  magnus  (long  thoracic  nerve):    Slight  rotation  of 

scapula;  difficulty  of  raising  arm  above  shoulder;  deep 
furrow  between  scapula  and  vertebrse  on  moving  arm  up- 
ward. 

3.  Pectorales  (anterior  thoracic  nerve) :     Impaired  abduction 

of  upper  arm ;  placing  of  affected  hand  on  healthy  shoulder 
impossible. 

4.  Teres  major  and  subscapular  (subscapular  nerve):    Loss  of 

inward  rotation  of  arm. 

5.  Infraspinatus  (suprascapular  nerve)  and  teres  minor  (axil- 

lary nerve):    Loss  of  outward  rotation  of  arm. 

6.  Latissimus  dorsi  (subscapular  nerve):    Impaired  abduction 

of  arm ;  inability  to  place  hand  on  sacrum. 

7.  Deltoid  (circumflex  nerve) :    Inability  to  elevate  arm ;  atro- 

phy. 

8.  Biceps  a7id  brachialis  anticus  (musculocutaneous) :    Inability 

to  flex  forearm,  when  in  supination;  inability  to  supinate 
forearm,  when  flexed. 

9.  Supinator  longus  and  brevis  (musculospiral  nerve) :   Weak- 

ened flexion  when  forearm  is  half-pronated ;  inability  to  su- 
pinate with  forearm  extended  and  pronated. 

10.  Triceps   and   the   extensors    ( muscido spiral   nerve,   "radial 

paralysis") :  Inability  to  extend  forearm  (in  triceps  pa- 
ralysis) ;  hand-drop  in  flexed  position ;  flexion  of  fingers ; 
impaired  abduction  and  adduction  (paralysis  of  the  ex- 
tensors) ;  impaired  sensation  along  radial  side ;  atrophy. 

11.  Flexor  carpi  ulnaris,  profundus  digitorum,  minimi  digiti, 

and  inner  head  of  brevis  pollicis;  the  interossei,  lumbricalis, 
palmaris  brevis  (ulnar  nerve,  "ulnar  paralysis") :  Claw- 
like deformity  of  hand. 

12.  Pronator  radii  teres,  pronator  quadratus,  palmaris  longus; 

flexors  carpi  radialis,  sublimis  digitorum,  profundus  digi- 
torum, and  longus  pollicis  (median  nerve,  "median  paral- 
ysis"):   Abolition  of  power  of  pronation;  inability  to  flex 


*See  also  "Birth  Palsy,"  p.  210. 


170  DISEASES    OF    CHILDREN 

terminal  phalanges  and  thumb;  objects  can  be  grasped 
with  the  last  three  fingers  only;  trophic  and  sensory  dis- 
turbance. 

(&)  Lower  extremities — 

1.  Gluteus  maximus  and  minimus  (gluteal  nerve) :     Difficulty 

to  abduct  thigh ;  to  walk  uphill ;  to  rise  from  sitting  pos- 
,     '  ture;  impairment  of  circumduction  and  inward  rotation, 

and  walking;  toes  are  turned  inward. 

2.  Anterior  muscles  of  thigh,   except  tensor  vaginae  femoris 

(anterior  crural  nerve,  "crural  paralysis") :  inability 
to  flex  thigh  on  trunk  and  to  flex  trunk  when  in  recumbent 
posture ;  to  extend  leg  when  flexed ;  difficulty  to  stand  or 
walk,  or  to  rise  from  kneeling  posture. 

3.  Obturator  externus  and  the  abductors   (obturator  nerve): 

Impaired  adduction  and  outward  rotation  of  thigh ;  ina- 
bility to  cross  legs. 

4.  Biceps,    semimembranosus,    semitendinosus — the    flexors    of 

knee  (great  sciatic  nerve) :  Inability  to  flex  knee ;  difficult 
locomotion ;  leg  inverted  or  everted. 

5.  Gastrocnemius,  soleus,  and  plantaris — the  extensors  of  the 

foot  (internal  popliteal  nerve):  Inability  to  extend  (plan- 
tar flexion)  of  foot,  to  stand  on  tiptoe;  difficulty  in  walk- 
ing; foot  everted,  ankle  lowered  (talipes  calcaneus). 

6.  Peroneus  longus  (musculocutaneous)  :    Foot  inverted ;  plan- 

tar arch  flattened  (flat  foot). 

7.  Tibialis  anticus,  and  extensor  longus  digit orum — flexors  of 

foot  (anterior  tibial  nerve) :  Impaired  flexion  ;  abduction 
and  adduction  (talipes  equinus). 

8.  Peroneus  brevis,  and  tibialis  posticus  (posterior  tibial  nerve) : 

Inability  to  adduct  or  abduct  foot  without  flexion  or  ex- 
tension. Talipes  valgus  in  tibial  paralysis ;  talipes  varus 
in  peroneal  paralysis. 

Peculiarities  of  g-ait — 

1.  Dragging,  in  multiple  sclerosis;  spastic  spinal  paralysis;  poli- 

omyelitis involving  both   legs;   amyotrophic   lateral   sclerosis; 
hemiplegia,  and  cretinism. 

2.  Straddling,  in  tabes  dorsalis. 

3.  Staggering,   reeling,   in   multiple   neuritis;   hereditary   ataxia; 

cerebellar  disease. 

4.  Waddling,  in  progressive  muscular  dystrophy;  bilateral  dislo- 

cation of  the  hips;  rachitis. 


EXAMINATION    OF    THE   PATIENT  171 

5.  Hobbling,  in  osteomalacia. 

6.  Shuffling,  in  hysterical  paralysis. 

Tendon  reflexes — 

(a)  Knee-jerk'^- — • 

1.  Exaggerated,  in  spinal  or  cerebral  paralysis,  associated  with 

"spasticity"  of  the  muscles  (see  p.  167)  ;  also  in  trans- 
verse myelitis  affecting  the  spinal  cord  above  the  second 
lumbar  vertebra ;  cerebellar  disease ;  general  nervousness. 

2.  Diminished  or  lost,  in  spinal  or  neural  affections  associated 

with  "flaccidity"  of  the  musculature   (see  p.  167)  ;  also 
in  transverse  myelitis  below  the  second  or  third  lumbar 
vertebra;  hereditary  ataxia;  "meningismus"  (early  stage). 
(6)  Ankle  clonus^ — 

1.  Absent  or  very  slight,  in  good  health. 

2.  Present,  and  often  very  pronounced,  in  cerebral  hemorrhage ; 

spastic  spinal  paralysis ;  dorsal  myelitis ;  disseminated  lat- 
eral sclerosis ;  hysterical  paralysis ;  tetanus. 
(c)  Periosteal  reflex^ — 

1.  Slight,  in  good  health. 

2.  Greatly  exaggerated,  in  cerebral  hemorrhage. 

Kernig's  sign  (inability  to  extend  legs  when  the  thighs  are  flexed  on 
abdomen)  :  In  divers  forms  of  meningitis;  occasionally  in  ty- 
phoid fever. 

Bahinski's  reflex  (extension  of  great  toe  with  flexion  of  other  toes 
on  crossing  sole  of  foot  with  index  finger) :  Pathognomonic 
of  meningitis  in  children  over  two  years  of  age,  in  organic 
hemiplegia. 

Brudzinski's  sign  (flexion  of  head  upon  chest  produces  simultaneous 
flexion  of  legs  towards  abdomen)  :  In  meningitis  and  polio- 
encephalitis. 

Weight  and  Length  of  Normal  Children 

An  exact  record  of  the  gain  or  loss  in  weight  of  the  patient  is  inval- 
uable in  the  diagnosis,  prognosis  and  treatment.  There  is  no  abso- 
lute standard  for  the  normal  weight  or  height  of  a  normal  infant  or 
older  child.  To  a  great  extent  it  depends  upon  the  race  the  child 
descends  from  and  also  upon  the  family  disposition.  Furthermore, 
the  size  of  the  child  is  not  always  an  indication  of  its  inherent  vigor. 
Ordinarily  boys  are  heavier  than  girls. 


'Obtained  by  a  sharp  blow  over  ligamentum  patellse,  while  lower  leg  hangs  loosely  down. 

-Rhythmic  oscillation  of  the  foot,  elicited  by  abruptly  pressing  toes  upward  with  one  hand, 
while  supporting  the  leg  with  the  other  hand. 

^Jerk  of  hand  or  forearm  i)roduced  by  a  tap  upon  the  tendons  of  the  supinator  longus  and 
biceps  at  lower  end  of  the  radius  and  ulna;  or  of  the  triceps  tendon,  at  the  olecranon. 


172 


DISEASES   OF    CHILDREN 


Fig.  29.— Buffalo  scale. 


WEEK   OF                                                                                                                                                                                                             WEEK   OF  AGE 

AGF       2       4        6       8       10     12     14     16     18    20     22     24     26     28     30     32     34     36     38     40 

19 

18 

17 

16 

15 

14 

|13 

§12 
a. 

11 
10 

9 
8 

7 

6 

5 

- 

19 

18 

17 

16 

15 

14 
c/> 

130 

z 

120 
a. 

11 
10 
9 
8 

7 
6 
5 

^ 

^ 

'^ 

Y^ 

^ 

k- 

' 

r* 

X 

,^ 

/> 

- 

y 

y 

y 

/ 

/ 

/ 

/ 

/ 

/ 

y 

/ 

/ 

- 

- 

- 

- 

/ 

/ 

/ 

_ 

_ 

J 

Fig.  30. — Normal  infant's  weight  chart. 


EXAMINATION    OP    THE   PATIENT 


173 


Circumference 

OF 

Age 

Weight 

Height 

Head 

Chest 

Abdomen 

Lbs. 

In. 

In. 

In. 

In. 

1 

Month 

8 

21.75 

13.75 

13.50 

13.50 

2 

Months 

101/2 

23.25 

15.40 

14.09 

14.09 

3 

Months 

12 

24.00 

15.80 

14.70 

14.70 

4 

Months 

14 

24.75 

16.14 

15.30 

15.30 

5 

Months 

14% 

25.21 

16.60 

15.88 

15.88 

6 

Months 

151/2 

25.75 

17.00 

16.07 

16.07 

7 

Months 

16% 

26.00 

17.16 

16.90 

16.75 

8 

Months 

17 

26.00 

17.37 

17.00 

17.00 

9 

Months 

17% 

26.75 

17.50 

17.25 

17.25 

10 

Months 

181/2 

27.25 

17.66 

17.50 

17.50 

11 

Months 

19% 

27.75 

17.82 

17.74 

17.75 

12 

Months 

20 

29.00 

18.00 

18.00 

18.00 

14 

Months 

21 

29.00 

18.16 

18.16 

18.16 

16 

Months 

22% 

29.50 

18.33 

18.33 

18.33 

18 

Months 

231/2 

30.00 

18.50 

18.50 

18.50 

20 

Months 

24 

30.50 

18.62 

18.62 

18.62 

22 

Months 

241/2 

31.00 

18.83 

18.83 

18.83 

24  Months 

25 

31.50 

19.00 

19.00 

19.00 

28 

Months 

27 

33.00 

19.16 

19.33 

19.16 

32 

Months 

29 

34.00 

19.33 

19.66 

19.33 

36 

Months 

31 

35.00 

19.50 

20.00 

19.50 

31/2  Years 

33 

36.50 

19.71 

20.50 

19.71 

4 

Years 

35 

38.00 

20.00 

21.00 

20.00 

4%  Years 

38 

38.50 

20.21 

21.21 

20.20 

5 

Years 

41 

41.50 

20.50 

21.50 

20.00                ^ 

Children  over  five  years  of  age  ordinarily  gain  about  5  pounds  in 
weight  and  2  inches  in  height  yearly  up  to  twelve  years  of  age. 
Weight  is — 

1.  Diminished,  rapidly,  in  cholera  infantum;  acute  febrile  diseases; 

athrepsia;  chronic  wasting  diseases,   especially  tuberculosis, 
malignant  growths  and  suppurative  processes;  diabetes. 

2.  Slowly,  in  dyspepsia ;  organic  affections  with  slow  course,  e.  g., 

heart  and  kidney  diseases.     (Avoid  mistaking  increasing  weight 
from  large  dropsical  effusion  for  natural  gain!) 

3.  Increased,  rapidly,  in  adipositas;  pituitary  disease  (Froehlich's 

syndrome)  ;  cretinism;  anasarca. 

4.  Increased,  slowly,  in  normal  health. 
Height  is — 

1.  At  a  standstill  or  nearly  so,  in  infantilism;  cretinism;  severe 

forms  of  rachitis;  achondroplasia;  in  marked  central  paralysis. 

2.  Increased,  rapidly,  in  disease  of  the  hypophysis ;  acute  febrile 

diseases,  especially  typhoid  fever. 

3.  Increased,  slowly,  in  normal  growth. 


CHAPTER  III 

CONGENITAL  MALFORMATIONS 

Congenital  malformations  depend  upon  the  following  causal  factors : 

1.  Hereditary  disposition  {e.g.,  supernumerary  fingers  and  toes). 

2.  Antenatal  constitutional  diseases,  especially  syphilis  and  tubercu- 
losis {e.g.,  hydrocephalus  and  spina  bifida). 

3.  Traumatism  during  pregnancy  (e.  g.,  multiple  fractures  and  dis- 
locations). 

4.  Extra-  or  intraabdominal  pressure  through  pelvic  deformities,  tu- 
mors, etc.     (e.  g.,  talipes). 

5.  Constriction  by  amniotic  bands  {e.g.,  amputations). 

CONGENITAL  MALFORMATIONS  OF  THE  HEAD 

Cephalocele  (Hernia  of  the  Brain) 

Meningocele,  Encephalocele,  Encephalocystocele  or 
'  Hydroencephalocele 

Congenital  defects  in  the  cranial  bones  permit  the  protrusion  of 
a  portion  of  the  contents  of  the  skull.     The  hernia  may  consist  of — 

{a)  Meninges  (which  form  the  hernial  sac)  with  or  without  cerebral 
fluid — meningocele.* 

(&)   Meninges  and  brain  substance — encephalocele. 

(c)  Meninges  and  brain  substance,  which  enclose  a  cavity  which  is 
filled  with  fluid  and  communicates  with  a  cerebral  ventricle — hydroen- 
cephalocele or  encephalocystocele. 

In  accordance  with  their  location  we  distinguish  the  following  forms 
of  cephalocele : 

(a)  Cephalocele  occipitalis  superior — situated  above  the  external  occip- 
ital protuberance. 

(&)   Cephalocele  occipitalis  inferior — situated  below  the  protuberance. 

(c)   Cephalocele  nasofrontalis — emerges  from  above  the  nasal  bones. 

{d)  Cephalocele  nasoethmoidalis — situated  below  one  of  the  nasal 
bones. 

(e)   Cephalocele  nasoorhitalis — appears  at  the  inner  angle  of  the  eye. 


•Congenital  meningocele  is  not  to  be  confounded  with  acquired  so-called  pseudomeningocele 
or  meningocele  spuria  s.  traumatica,  which  is  either  a  result  of  trauma  during  delivery  or  a  ca- 
rious process,  especially  syphilis.  Here  the  tumor  is  usually  situated  at  one  of  the  parietal  bones, 
increases  in  size  with  the  development  of  the  brain  or  enlargement  of  the  cleft  in  the  bone. 

174 


CONGENITAL    MALFORMATIONS  175 

The  presenting  tumor  varies  in  size  from  a  small  nut  to  a  fetal  head. 
It  may  be  flat,  sessile,  hemispherical,  pear-shaped  or  pedunculated. 
Small  tumors  are  soft  and  elastic,  larger  ones  pulsate  and  are  often 
translucent.  They  enlarge  during  crying,  and  may  be  I'educed  in  size 
by  compression,  a  procedure  Avhich  is  usually  attended  by  meningeal 
disturbances.  B}"  bearing  in  mind  the  characteristic  signs,  there  ought 
to  be  no  difficulty  in  differentiating  cephaloceles  from  extracranial 
cysts,  hematomas,  abscesses,  etc.  The  diagnosis  may  be  facilitated 
by  an  x-ray  examination,  showing  the  edges  of  the  opening  in  the  bone. 
Cephaloceles  may  remain  small  and  give  rise  to  but  very  little  dis- 
turbance. As  a  rule,  however,  they  grow  rapidly  and  produce  death 
from  meningitis,  convulsions,  or  rupture,  or  proceed  a  slower  course 
manifested  by  more  or  less  pronounced  backwardness  in  physical  and 
mental  development  and  other  evidences  of  organic  brain  disease. 

Small  cephaloceles  require  no  surgical  interference,  but  merely  pro- 
tection against  external  injuries  by  suitable  caps,  etc.,  or  gentle  com- 
pression after  reposition  of  the  protrusion.  Inoperable  cases  are  those 
complicated  by  pronounced  flattening  or  diminution  in  size  of  the 
skull,  by  hydrocephalus  or  other  serious  malformations,  or  where  the 
cleft  in  the  skull  reaches  down  to  the  foramen  magnum.  In  all  other 
eases  removal  of  the  protruding  brain  is  the  only  proper  treatment,  fol- 
lowed, if  necessary,  by  osteoplastic  closure  of  the  defect  in  the  skull. 

As  the  operation  is  not  rarely  successful,  if  performed  by  a  skillful 
surgeon;  and  as  the  prognosis  is  extremely  grave  in  large  tumors  if 
let  alone,  there  is  sufficient  justification  for  early  ( !)  surgical  inter- 
ference. 

Hydrocephalus  (See  pp.  117,  596,  710), 

Microcephalus  (See  p.  707), 

CONGENITAL  MALFORMATIONS  OF  THE  FACE 
Including-  Those  of  the  Palate,  Mouth,  Eyes,  Nose  and  Ears 

Clefts  of  the  Face  and  Lips 

1.  Median,  the  result  of  nonunion  of  both  globular  processes  of  the 
central  nasal  process.     This  cleft  is  rarely  extensive, 

2,  Lateral  (lahiimi  leporinum,  harelip,  cheiloschisis),  produced  by 
failure  of  union  of  one  or  both  globular  processes  with  the  superior  max- 
illary processes.  Clefts  of  the  upper  lip  may  accordingly  be  unilateral  or 
bilateral,  may  exist  as  a  mere  notch  into  the  skin  margin  of  the  lip,  or, 
more  frequently,  extend  for  some  distance  upward,  involving  the  whole 
lip,  nostril  and  upper  jaw.    It  is  occasionally  associated  with  cleft  palate. 


176 


DISEASES   OF    CHILDREN 


3.  Ohlique  (meloschisis),  arises  from  defective  closure  of  the  groove 
between  the  lateral  nasal  process  and  the  superior  maxillary  process. 
The  cleft  runs  as  high  as  the  lower  lid. 

4.  Transverse  (macrostomm),  as  a  result  of  patency  of  the  groove  be- 
tween the  superior  maxillary  process  and  the  first  branchial  arch  (man- 
dibula). 

Occasionally  fistulas  and  fissures  are  observed  in  the  bridge  of  the 
nose  and  lower  lip. 

For  details  of  treatment  the  reader  is  referred  to  text  books  on  surgery. 


Fig.  31.— Harelip. 

Cleft  Palate  (Palatum  Fissum,  Palatoschisis) 

It  is  due  to  defective  union  of  the  processes  of  the  superior  maxil- 
lary and  palate  bones  which  during  intrauterine  life  normally  grow 
inward  to  meet  the  vomer  in  the  middle  line  and  the  intramaxillary 
bone  in  front  to  form  the  hard  and  soft  palates. 

1.  Complete  (Uranoschisma) . — The  fissure  extends  in  the  middle  line 
through  the  uvula  and  the  soft  and  hard  palates,  and  thence  through 
the  alveolar  process  in  the  line  of  suture  either  on  one  or  both  sides  of 
the  intramaxillary  bone.  It  is  generally  combined  with  double  or  single 
harelip,  and  is  then  designated  ''Wolf's  Jaw." 

2.  Partial  (Uranocolohoma) . — It  may  involve  the  uvula  only,  or  part 
of  the  soft  and  hard  palates  as  well.  Sometimes  it  is  limited  to  a  mere 
notching  of  the  alveolar  process  on  one  or  both  sides  and  forms  the 
continuation  of  uni-  or  bilateral  harelip. 

The  consequences  of  cleft  palate,  if  extensive  in  degree,  are  by  far 
more  serious  than  those  of  cleft  lip.  Suction  and  deglutition  are  greatly 
interfered  with.  In  older  children  the  voice,  articulation,  sense  of  taste, 
smell,  and  hearing  may  all  be  impaired. 


CONGENITAL    MALFORMATIONS  177 

The  management  of  cleft  palate  is  principally  surgical.  The  earlier 
the  operation  is  undertaken  the  more  perfect  are  the  results.  The  mode 
of  feeding  frequently  presents  great  difficulty.  Infants  born  with  marked 
cleft  palate  who  are  unable  to  nurse  have  to  be  fed  artificially  either 
with  the  spoon  or  through  a  tube  passed  through  the  nose  into  the 
stomach.  A  vulcanized  rubber  plate  covering  the  defect  in  the  palate 
often  acts  admirably. 

Defects  of  the  Mouth  and  Tongue 

Atresia  Oris  (Microstomia). — The  lips  may  be  grown  together  par- 
tially or  completely.  In  the  latter  event  an  immediate  plastic  opera- 
tion is  inevitable.  Congenital  microstomia  should  not  be  confounded 
with  the  acquired  contractures  of  the  oral  orifice  resulting  from  syph- 
ilis, gangrene,  burns,  etc. 

Adhaesio  Lingiiae  (Ankylog-lossia,  Tongue-Tie) . — It  is  produced  by 
a  large  and  anteriorly  displaced  frenulum,  and  varies  greatly  in  de- 
gree, the  insertion  of  the  frenulum  sometimes  extending  so  far  for- 
ward as  to  interfere  with  suckling,  and,  later,  with  speech. 

The  anomaly  may  be  removed  by  nicking  the  frenulum  wdth  a  scis- 
sors, and  further  ''loosening  of  the  tongue-string"  with  the  finger,  thus 
avoiding  injury  to  the  ranine  artery  (dangerous  in  hemophilia!).  The 
rare  adhesion  between  the  epithelial  surfaces  of  the  tongue  and  the 
floor  of  the  mouth  can  be  liberated  in  a  similar  manner, 

Macroglossia  (Large  Tongue). — Enlargement  of  the  tongue  may 
be  due  to  a  true  lymphangiomatous  tumor  (cavernous  macroglossia), 
or  to  a  fibrous  hypertrophy  (fibrous  macroglossia).  Both  forms  may 
coexist.  The  tongue  may  be  so  markedly  enlarged  as  to  find  no  room 
in  the  mouth,  and  by  protruding  from  it  become  bruised,  chapped 
and  cracked,  assume  such  dimensions  as  to  render  suckling  very  diffi- 
cult or  impossible,  and  possibly  lead  to  a  fatal  issue  from  inanition. 
Congenital  macroglossia  from  the  aforementioned  causes  is  not  to 
be  mistaken  for  protrusion  of  the  tongue  associated  with  cretinism. 
Mild  degrees  of  macroglossia  usually  improve  spontaneously  with 
the  growth  of  the  oral  cavity ;  severe  forms  call  for  removal  of  a  wedge- 
shaped  piece  of  the  protruding  tongue. 

Malformations  of  the  Eyes 

Anophthahnus  (Absence  of  One  or  Both  Eyes). — This  is  a  rare  mal- 
formation. In  a  great  many  cases  careful  anatomic  examination  re- 
veals the  presence  of  rudimentary  eyes.  If  only  one  eye  is  absent, 
the  existing  eye  may  be  perfectly  normal  or  defective  in  various  ways. 


178  DISEASES    OF    CHILDREN 

Microphthalmus. — An  abnormally  small  eye  causes  more  or  less  se- 
vere disturbance  of  vision  which  may  in  some  instances  be  relieved 
by  suitable  glasses.  It  is  sometimes  associated  with  adhesion  of  the 
edges  of  the  ej'elids  (ankylohlepharon,  crijptopldhalmus) ,  and  other 
abnormalities  of  the  bulb,  which  may  require  surgical  treatment. 

Atresia  Pupillse  Congenita. — Occasionally  the  pupillary  membrane 
persists  after  birth  and  varying  with  its  extent  leads  to  more  or  less 


Fig.  32. — Bilateral  congenital  anophthalmia. 

grave  visual  defects.  The  fine,  gray  membrane  may  be  mistaken 
for  an  exudation  or  capsular  cataract.  Spontaneous  improvement  is 
the  rule. 

Cataracta  Congenita. — It  is  usually  partial,  rarely  complete.  It  may 
exist  in  the  form  of  limited  opacities  and  not  be  recognized  until  school 
age.  In  the  complete  variety  the  condition  may  present  a  white  pu- 
pil. Zonular  or  lamellar  cataract  may  be  acquired  during  early  in- 
fancy as  a  result  of  faulty  metabolism  or  during  the  course  of  tetany. 
It  often  remains  stationary  for  many  years. 


CONGENITAL    MALFORMATIONS  179 

Treatment. —If  suitable  glasses  give  the  patient  sufficient  vision  for 
educational  and  other  purposes,  an  operation  may  be  indefinitely 
postponed.  Otherwise  discission,  iridectomy  or  lenticular  extraction 
is  indicated. 

Coloboma  Iridis  (Iridoschisma,  Fissure  of  the  Iris). — It  is  usu- 
ally bilateral  and  sometimes  associated  with  coloboma  of  the  choroid, 
fissure  of  the  upper  eyelid  without  involvement  of  the  external  skin, 
microphthalmus,  and  cataract.  If  uncomplicated,  it  disturbs  the  vision 
but  slightly. 

Irideremia  (Aniridia). — Partial  or  complete  absence  of  the  iris  usu- 
ally occurs  on  both  sides  and  is  associated  with  abnormality  of  the 
cornea  and  poor  vision.  The  pupils  are  iridescent  like  cat's  eyes,  and 
owing  to  too  strong  perception  of  light,  the  affected  children  con- 
vulsively open  and  close  the  eyelids.  The  same  phenomenon  is  often 
observed  in  alhinisni — a  condition  in  which  there  is  a  congenital  defi- 
ciency of  pigment  in  the  iris  and  choroid.  Albinos  have  a  blue  iris 
and  very  fair  complexion. 

Treatment. — Exclusion  of  superabundance  of  light  by  means  of  dark 
glasses  or  artificial  diaphragm. 

Malformations  of  the  Nose 

Adhesions  Between  the  Turbinated  Bones,  Particularly  the  Inferior, 
and  the  Septum. — The  adhesions  may  be  membranous  or  bony,  and 
not  rarely  associated  with  deflection  of  the  septum.  The  treatment  is 
the  same  as  in  the  acquired  adhesions. 

Atresia  of  the  Posterior  Nares. — The  closure  may  be  membranous 
or  bony ;  in  the  latter  condition  there  is  bony  union  between  the  palate 
and  the  sphenoid.  If  the  closure  is  only  moderately  firm,  it  can  be 
perforated  by  a  stout  probe  or  galvanocautery.  Firm  bony  unions 
giving  rise  to  difficult  suckling  call  for  the  employment  of  chisel  and 
mallet  or  trephine,  using  finger  in  the  nasopharynx  as  a  guide  to  pre- 
vent the  instrument  from  penetrating  too  deeply. 

Malformations  of  the  Ears 

Fissures  and  Fistulas  of  the  Ear. — Fissures  (beneath  the  tail  of  the 
helix)  and  fistulas  (in  front  of  and  above  the  tragus)  are  occasionally 
observed,  especially  in  connection  with  other  congenital  malformations. 
Deep  fistulae  sometimes  secrete  a  serous  fluid  not  rarely  causing  intracta- 
ble eczema  and  requiring  operative  interference. 

Auricular  appendages  in  the  form  of  scattered  round  or  oblong, 
smooth  or  warty  pieces  of  cartilage  are  not  rarely  found  in  front 
of  the  ear.    They  can  readily  be  removed  by  knife  or  electric  cautery. 


180  DISEASES   OF    CHILDREN 

Ear  prominence  is  a  malformation  which  can  often  be  remedied  in 
the  newborn  by  keeping  the  ear  properly  bandaged  for  several  weeks. 
Sometimes  it  calls  for  a  slight  operation. 

Atresia  auris,  absence  of  the  auditory  meatus,  is  most  frequently 
complete,  involving  the  cartilaginous  as  well  as  the  bony  portion  of 
the  canal.  Moreover,  there  is  usually  also  an  abnormal  tympanic  mem- 
brane. Hence  very  little  benefit  can  be  expected  from  operative  inter- 
ference. 

All  sorts  of  ear  deformities  are  encountered  in  connection  with  idiocy 
and  the  allied  mental  deficiencies  (q.  v.). 

MALFORMATIONS  OF  THE  LARYNX  AND  TRACHEA 

Congenital  Diaphragm  of  the  Larynx. — The  glottis  is  more  or  less 
occluded  by  a  membrane  running  transversely  across  the  vocal  cords. 
The  symptoms  stand  in  direct  relation  to  the  size  of  the  remaining 
opening. 

In  marked  cases  the  membrane  should  be  excised  after  preliminary 
tracheotomy. 

Laryngocele  and  Tracheocele  (Aerocele). — The  tumor  is  situated 
laterally  or  in  the  median  line.  It  increases  in  size  on  coughing  or 
crying  and  diminishes  on  pressure. 

The  treatment  consists  of  excision  of  the  cyst  and  closure  of  the 
communication  with  the  respiratory  tube. 

Stridor  Congenitus  (Child-Crowing). — This  congenital  anomaly  is  not 
to  be  confounded  with  laryngospasmus  (spasmus  glottidis,  see  p.  677) 
w^hich  is  an  acquired  affection  and  forms  a  symptom  of  spasmophilia 
iq.v.). 

The  etiology  is  still  indefinite,  although  in  a  number  of  cases  the 
stridor  could  be  traced  to  malformation  of  the  epiglottis  and  hypertro- 
phy of  the  thymus  gland. 

Stridor  congenitus  is  manifested  by  a  loud,  crowing  inspiration,  ac- 
companied by  retraction  of  the  jugulum  and  epigastrium.  It  is  free 
from  cyanosis  or  any  systemic  disturbance,  and  usually  subsides  spon- 
taneously in  the  course  of  a  year  or  so. 

MALFORMATIONS  OF  THE  NECK 

Fistula  Colli  Congenita. — This  is  a  rare  anomaly,  the  result  of  de- 
fective closure  of  the  second  and  third  branchial  arches.  The  fistula 
is  situated  either  laterally  immediately  above  the  sternoclavicular  ar- 
ticulation, or  medianly  at  a  varying  level  between  the  hyoid  bone 
and  the  jugulum.    The  fistula  becomes  apparent  by  its  fine,  pinhead- 


CONGENITAL    MALFORMATIONS  181 

sized  opening  with  an  irregular,  moist  surface.  By  passing  a  fine  probe 
the  fistula  is  found  to  end  either  blindly  or  in  the  pharynx  or  esopha- 
gus. So  long  as  its  track  is  free,  the  fistula  gives  rise  to  no  serious 
symptoms.  Its  occlusion,  however,  is  associated  with  danger  of  re- 
tention of  the  mucoid  secretion  and  cyst  formation.  Hence  the  indi- 
cation for  complete  extirpation  of  the  fistulous  canal. 

Branchial  Appendages. — These  occur  in  the  shape  of  warts,  nipples 
or  mushrooms,  along  the  margin  of  the  sternomastoid,  between  the 
sternoclavicular  region  and  the  hyoid  bone,  consist  of  skin  alone  or  of 
skin  and  cartilage,  and  are  frequently  associated  with  auricular  at- 
tachments (q.v.).  They  cause  no  annoyance  except  from  a  cosmetic 
point  of  view.     They  are  readily  removable  and  nonrecurrent. 

Branchiogenetic  Cysts. — The  seat  of  these  variously  sized  (from  a 
small  nut  to  a  hen's  egg),  elastic,  serous,  seromucous,  sebaceous,  some- 
times dermoid  cysts  is  the  anterior  region  of  the  neck  (in  the  middle 
line  or  at  the  side).  The  cyst  contents  may  become  purulent  through 
infection  or  sanguinolent  through  involvement  of  a  blood  vessel.  As- 
piration is  a  useful  aid  in  the  diagnosis,  and  extirpation  of  the  cyst 
the  only  rational  mode  of  treatment. 

Hygroma  Cysticmn  Colli  Congenitum  (Ljrmphangioma  Cysticum). — 
This  tumor  consists  of  a  number  of  small  or  large  communicating  or 
noncommunicating  cysts.  It  varies  in  size  from  a  slight  swelling  under 
the  lower  jaw  or  over  the  clavicle  to  an  enormous  tumor  embracing 
the  whole  neck,  and  extending  downward  to  the  chest  and  upward 
to  the  face.  It  may  even  involve  the  mouth,  throat,  base  of  the  cranium 
and  mediastinum.  In  the  latter  event  the  prognosis  is  extremely 
grave.  As  the  removal  of  large  tumors  is  attended  by  great  diffi- 
culties, it  is  often  justifiable  first  to  try  aspiration  with  subsequent 
injection  of  iodine  or  incision  and  antiseptic  packing.  Small  hygromas 
should  unhesitatingly  be  extirpated. 

Cervical  Rib. — The  supernumerary  rib  is  a  hard,  bony  clasp  which  be- 
gins usually  at  the  seventh  or  sixth  cervical  vertebra  and  either  ends  there 
as  a  small  protuberance  or  continues  farther  to  join  the  first  thoracic 
rib  or  even  the  sternum.  It  may  be  unilateral  or  bilateral  (Fig.  33). 
The  symptomatology  depends  upon  the  degree  of  pressure  exerted  by 
the  rib  upon  the  neighboring  structures,  especially  the  subclavian 
artery  and  some  branches  of  the  brachial  plexus  (neuritis) ;  sometimes 
there  is  dilatation  of  the  pupil  owing  to  pressure  paralysis  of  the  cervi- 
cal sympathetic  nerve.  As  a  rule,  the  symptoms  do  not  become  mani- 
fest until  the  child  has  reached  the  age  of  eight  years  or  later.  The 
diagnosis  must  rest  chiefly  upon  a  very  careful  roentgen-ray  examina- 
tion.    A  nine-year-old  girl  under  my  observation  was  for  two  years 


182 


DISEASES   OF    CHILDREN 


treated  for  cervical  spondylitis  without  the  slightest  benefit,  until  at 
last  an  exact  radiogram  disclosed  the  presence  of  a  cervical  rib  on 
the  right  side. 

Treatment. — Where   the   symptoms   are   mild,   palliative   therapeutic 
measures,  such  as  rest,  massage  and  electricity  for  the  relief  of  pain, 


Fig.   33. — Large   asymmetrical  cervical  ribs;    neuritis  and   vascular   disturbances   in 
the  right  arm.     (Dr.  A.  Church.) 

usually  suffice.  On  the  other  hand,  cases  presenting  severe  vascular, 
nervous  and  trophic  disturbances  call  for  extirpation  of  the  super- 
numerary rib,  an  operation  demanding  great  surgical  skill. 


MALFORMATIONS  OF  THE  THORAX 

Defects  of  the  Sternum. — Partial  or  complete  absence  or  smaller  con- 
genital clefts  of  the  sternum  are  of  rare  occurrence.  They  give  rise 
to  hernial  protrusions  of  the  lung,  which  if  small  in  size  are  apt  to 
be  mistaken  for  soft  tumors  or  abscesses.  Lung  hernia  is  reducible  on 
pressure,  changes  in  size  and  shape  with  respiration,  and  is  frequently 
associated  with  paroxysms  of  coughing. 

Among  the  diverse  deformities  of  the  sternum,  congenital,  non- 
rachitic "funnel  chest"  is  deserving  of  special  mention.  It  differs 
from  acquired  rachitic  funnel-shaped  chest  by  the  absence  of  other 
rachitic  deformities. 

Anomalies  of  the  Ribs. — ^One  or  more  ribs  may  be  absent  or  rudi- 
mentarily  developed.    The  intervening  space  is  filled  with  membrane. 


CONGENITAL    MALFORMATIONS  183 

There  may  also  be  accessory  ribs  (see  "Cervical  Kib,"  p.  181,  or  sev- 
eral ribs  may  be  united. 

Defects  of  the  Thoracic  Muscles. — Congenital,  partial  or  total  ab- 
sence of  one  or  several  of  the  thoracic  muscles  is  apt  to  be  mistaken 
for  progressive  muscular  dj^strophy.  The  former,  however,  is  uni- 
lateral, while  the  latter  is  bilateral.  Secondary  scoliosis  is  apt  to 
follow  the  congenital  muscular  defects. 

All  the  aforementioned  malformations  of  the  thorax  require  some 
mechanical  contrivance,  to  prevent  either  injury  to  the  internal  struc- 
tures or  secondary  deformities. 

MALFORMATIONS  OF  THE  ALIMENTARY  TRACT 

Atresia  Esophagi. — ^Congenital  esophageal  strictures  are  very  rare. 
They  give  rise  to  difficulty  of  swallowing  and  immediate  regurgita- 
tion of  the  food  through  the  mouth  and  nose.  Introduction  of  a 
bougie  shows  the  seat  of  the  obstruction. 

The  treatment  is  the  same  as  in  acquired  esophageal  strictures.  Ow- 
ing to  the  absence  of  true  scar  tissue  in  the  congenital  form,  the  pros- 
pects of  recovery  are  brighter. 

Stenosis  Pylori  Congenita. — (See  p.  242.) 

Congenital  Stenoses  and  Atresias  of  the  Intestines 

Any  portion  of  the  intestines  may  be  congenitally  malformed  or 
completely  obliterated.  Partial  stenosis  is  most  frequently  observed 
in  the  small  intestine,  while  complete  atresia  occurred  more  frequently 
in  the  rectum  and  anus.  Pathologically  it  is  found  that  the  lumen  of 
the  intestine  above  the  occlusion  is  widely  dilated,  while  that  below  it  is 
more  or  less  collapsed. 

The  symptoms  vary  with  the  seat  of  the  lesion.  The  higher  the 
stenosis,  the  earlier  and  more  pronounced  the  vomiting,  the  larger 
the  quantity  of  the  meconium,  and  the  more  marked  the  dyspnea, 
and  eventually  the  cyanosis  as  a  result  of  compression  of  the  thoracic 
organs  by  the  highly  distended  stomach. 

On  the  other  hand,  the  lower  the  stenosis,  the  more  fecal  the 
vomiting,  the  greater  the  meteorism,  and  the  more  marked  the  dis- 
turbances of  the  bladder  and  kidney  (partial  or  total  anuria  as  a 
result  of  compression  of  the  ureters  by  the  highly  distended  intes- 
tines). In  stenosis  of  the  duodenum  the  vomitus  contains  bile  sub- 
stances. 

Associated  with  the  local  symptoms  of  intestinal  stenosis  are:  dry 
tongue,  subnormal  temperature,  rapid  emaciation,  pinched  features  of 


184  DISEASES   OF    CHILDREN 

the  face,  and  collapse.  Death  usually  takes  place  -within  a  week. 
Where  the  stenosis  is  only  partial  and  slight,  the  child  may  linger  for 
months  and  ultimately  recover. 

In  mild  cases  the  treatment  should  be  symptomatic,  principally  to 
relieve  constipation  and  to  mitigate  the  pain  and  agony.  Surgical 
intervention  as  a  last  resort. 

Congenital  Hypertrophy  and  Dilatation  of  the  Colon 

(Megacolon  Congenitum,  Hirschsprung's  Disease) 

This  congenital  affection  should  not  be  mistaken  for  acquired  dila- 
tation of  the  large  bowel  associated  with  intestinal  atony  from  various 
causes. 


Fig,  34. — Moderate  degree  of  megacolon  congenitum  or  Hirschsprung's  disease,  in  a 

child  three  years  old. 

The  congenital  dilatation  is  manifested  soon  after  birth  by  retention 
of  the  meconium,  although  the  child  is  otherwise  apparently  healthy 
and  free  from  congenital  stenosis  of  the  anus  or  rectum.     Intestinal 


CONGENITAL    MALFORMATIONS 


185 


irrigation  brings  forth  but  a  small  quantity  of  feces.  The  infant  is 
restless  and  constipated,  and  its  abdomen  gradually  becomes  greatly 
distended.  Some  time  later  the  constipation  is  followed  by  more 
or  less  copious  diarrhea  due  to  intestinal  irritation  from  retained  feces. 
After  expulsion  of  the  stool  and  gas,  the  abdomen  is  reduced  in  size, 
but  after  a  short  time  it  again  becomes  distended,  giving  rise  to  the 
aforementioned  symptoms.  Most  infants  succumb  early  to  the  disease, 
from  interference  with  the   thoracic   organs   or   autointoxication   by 


Fig.  35. — Congenital  absence  of  anus  and  rectum  and  of  scrotum  and  its  contents. 

the  decomposing  intestinal  contents;  others  may  live  longer  and  in 
rare  instances  even  entirely  recover. 

Postmortem  examination  reveals  either  of  the  following  conditions: 
(1)  Simple  dilatation  and  often  lengthening  of  the  colon;  (2)  ectasis 
of  a  section  of  the  colon  with  or  without  compensating  dilatation  or 
hypertrophy  of  the  adjoining  portions;  (3)  general  enlargement  of  the 
intestinal  lumen  and  hypertrophy  of  its  walls.  The  hypertrophy  usu- 
ally involves  the  longitudinal  and  circular  muscular  fibers. 

The  treatment  is  chiefly  symptomatic  (see  "Constipation")  ;  in  severe 
cases  surgical  intervention. 


186 


DISEASES   OF    CHILDREN" 


Atresia  of  the  Rectum  and  Anus 

Atresia  Ani  Proper  (Imperforate  Anus). — The  rectum  is  normal  and 
ends  blindly  into  the  completely  closed  anus.  There  may  not  be  the 
slightest  indication  of  an  anus,  or  the  latter  is  indicated  by  a  few 
comb-like  prominences,  a  small  fossa,  or  a  round  indulation. 

Atresia  Recti. — The  anus  is  normally  developed,  but  the  rectum  ends 
blindly  somewhere  higher  up  in  the  canal. 


Fig.  36. — Stomach  and  intestines  of  case  shown  in  Tig.  35,  showing  ending  of  colon 
in  a  blind  pouch  filled  with  meconium. 

Atresia  Ani  et  Intestini  Recti. — In  this  condition  the  anal  orifice  is 
absent  and  the  rectum  is  arrested  in  its  development  higher  up,  usu- 
ally in  the  region  of  the  sacroiliac  symphysis. 

Atresia  Ani  Complicata. — There  is  atresia  of  the  anus,  and  the 
rectum  terminates  either  (1)  in  the  bladder  (atresia  recti  vesicalis); 
(2)  in  the  vagina  (atresia  recti  vaginalis),  or  somewhere  in  the  urethra 
(atresia  recti  urethralis). 

Atresia  Recti  cum  Fistula. — The  anus  proper  is  occluded;  the  rec- 
tum ends  blindly,  but  is  connected  with  the  outer  skin  by  a  fistulous 


CONGENITAL    MALFORMATIONS 


187 


tract.  The  anal  orifice  is  thus  located  in  an  abnormal  position  in  the 
perineum,  vulva,  scrotum,  etc. 

The  diagnosis  of  imperforate  anus  or  rectum  usually  presents  no 
difficulty.  Imperforate  anus  can  readily  be  made  out  by  inspection. 
Absence  of  meconium  in  the  presence  of  a  normal  anus  indicates  that 
the  defect  is  som.eAvhere  higher  up.  Digital  or  instrumental  exam- 
ination rarely  fails  to  locate  the  seat  of  obstruction.  Atresia  ani  com- 
plicata  may  be  detected  by  the  presence  of  meconium  in  the  urine 
or  by  continuous  escape  of  feces  from  the  abnormal  communications. 
The  latter  symptom  is  indicative  also  of  atresia  recti  cum  fistula,  which 
can  readily  be  seen. 

Imperforate  anus  and  rectum  are  the  only  two  conditions  giving 
rise  to  immediate  more  or  less  grave  symptoms.  The  child  passes  no 
meconium,  appears  restless,  strains,  cries,  its  abdomen  is  distended, 
it  suffers  from  dyspnea,  and  vomits  occasionally.  If  not  relieved,  it 
succumbs  Avithin  a  week  from  rupture  of  the  intestines  and  peritonitis. 
I^rompt  operative  interference  is  therefore  imperative.  If  the  ob- 
struction is  in  the  anus,  or  in  the  lower  part  of  the  rectum,  puncture 
or  incision  with  consecutive  dilatation  will  often  suffice  to  effect  a 
cure.  Whenever  the  point  of  the  atresia  cannot  be  discerned,  an  arti- 
ficial anus  should  be  made  for  quick  relief,  postponing  the  curative 
measures  for  later.  An  operation  should  be  postponed  also  in  all 
other  forms  of  atresia  ani  or  recti,  where  the  escape  of  meconium  is 
not  entirely  interfered  with. 

DEFECTS  OF  THE  ABDOMINAL  PARIETES 

Diastasis  Recti  Abdominis. — Lozenge-shaped  separation  of  the  ab- 
dominal wall,  extending  from  the  xiphoid  to  the  umbilicus,  is  con- 
genital in  nature  and  due  to  defective  closure  of  the  deep  layers  of 


Fig.  37. — Diastasis  recti  abdominis  in  an  amaurotic  idiot. 


188 


DISEASES   OF    CHILDREN 


the  abdominal  coverings.     It  is  sometimes  associated  Avith  umbilical 
hernia. 

The  symptoms  make  their  appearance  when  the  child  is  able  to 
run  and  jump,  and  consist  of  sudden  attacks  of  colic  (not  to  be  mis- 
taken for  enteralgia !),  uneasiness  in  the  epigastric  region,  pallor,  etc., 
which  subside  when  the  child  is  perfectly  at  rest.  These  paroxysms 
are  due  to  partial  incarceration  of  the  stomach  in  the  abdominal  slit, 
and  should  be  remedied  by  bringing  and  keeping  the  separated  recti 
muscles  together  by  means  of  plaster  straps  or  suitable  bandage. 

Cong-enital  Umbilical  Hernia 

(Hernia  Funiculi  Umbilicalis,  Exomphalos,  Omphalocele 

Congenita,  Ectopia  Viscerum,  Amnion  Navel) 


Fig.  38. — Congenital  umbilical  hernia. 

As  a  result  of  faulty  development  of  the  abdominal  coverings,  in- 
stead of  an  umbilicus,  a  variously  sized,  sac-like  dilatation  is  occa- 
sionally observed  which  may  contain  intestinal  loops,  the  stomach, 
liver,  spleen,  etc.    The  hernial  sac  is  composed  of  the  amnion  and  pari- 


CONGENITAL    MALFORMATIONS 


189 


Fig.  39. — Congenital  femoral  hernia. 


Fig.  40. — Ectopia  viscerum. 


Fig.  41. — Thoracoabdominopagus  with  prolapse  of  intestines. 


190 


DISEASES   OF    CHILDREN 


etal  peritoneum.  At  birth  the  contents  of  the  sac  can  usually  be  rec- 
ognized through  the  thin,  transparent  membranes,  but  small  protru- 
sions into  the  cord  are  apt  to  be  overlooked,  and  carelessly  tied  off 
with  the  umbilical  rest.     If  there  is  considerable  eventration,  the  in- 


Fig.  42. — Skiagram  of  tlioracoabdominopagus.     (Same  as  Fig.  41.) 

fants  die  early  from  rupture  of  the  sac  and  peritonitis.  The  first  indi- 
cation therefore  is  to  replace  the  prolapsed  structures  into  the  ab- 
dominal cavity  and  to  keep  them  there  by  means  of  a  suitable  bandage. 
In  this  manner  small  hernias  not  rarely  subside  spontaneously.  Large 
hernias  should  be  treated  by  a  radical  operation. 

Persistence  of  the  Ductus  Omphalomesentericus 

(VlTELLOINTESTINAL   DuCT) 

Physiologically,  the  omphaloentericus  duct,  the  embryonic  tubular 
communication  between  the  intestinal  canal  and  the  germinal  vesicle, 


CONGENITAL    MALFORMATIONS  191 

disappears  at  about  the  eip:lith  week  of  fetal  life.  Occasionally  the 
duct  is  not  obliterated,  and  leads  to  the  following  principal  abnor- 
malities: 

1.  A  fine  fistula  at  the  umbilical  ring,  forming  a  communication 
between  the  bowels  and  the  exterior,  and  secreting  a  cloudy  fluid  con- 
taining a  trace  of  fecal  matter. 

2.  A  hernial  protrusion  through  the  umbilicus  in  the  form  of  a  red 
finger-shaped  tumor  which  is  usually  composed  of  the  prolapsed  walls 
of  the  fistula,  but  sometimes  of  intestinal  loops. 

3.  Open  Meckel's  diverticulum.  It  is  a  blind  appendage  of  the  lower 
part  of  the  ileum,  and  may  be  free  or  united  Avith  the  umbilicus  by 
a  solid  cord.  Under  certain  condition.s  it  may  enter  a  hernial  sac  and 
here  become  strangulated.  It  may  produce  "ileus"  by  incarcerat- 
ing some  loops  of  the  intestines,  and  give  rise  to  local  intestinal  in- 
flammation closely  resembling  that  of  appendicitis. 

Persistent  omphaloenteric  duct  may  be  mistaken  for:  (1)  persis- 
tent urachus — on  examination  with  the  catheter  it  can  be  reached 
through  the  bladder;  the  secretion  is  composed  chiefly  of  urine;  (2) 
sareomphalos — has  no  fistular  opening. 

Fine  fistulas  frequently  close  after  repeated  cauterization  with  the 
caustic  stick.  Wherever  the  prolapse  is  very  marked,  or  in  cases 
associated  with  open  diverticula,  a  radical  operation  is  imperative, 
since  their  presence  is  always  a  menace  to  life. 

Urachus  Fistula 

(FissuRA  Vesic/E  Umbilicalis) 

Persistent  urachus — the  duct  through  which  the  urinary  bladder 
communicates  with  the  allantois — gives  rise  to  a  fistulous  tract  which 
ends  at  the  umbilicus.  On  pressure  a  small  hernial  tumor  arches 
forward  and  secretes  a  clear  or  turbid  fluid,  composed  of  urine  alone, 
or  urine,  mucus  and  pus.  If  the  fistula  is  large,  the  flow  may  be  con- 
tinuous. It  may  give  rise  to  cystitis  and  even  pyelonephritis  compell- 
ing early  operative  procedures.  The  first  attempt  at  a  cure  should 
be  directed  to  making  the  natural  outlet  free  (e.g.,  cure  of  phimosis). 
Small  fistulffi  often  yield  to  cauterization  and  continued  pressure  with 
a  bandage.  If  this  fails,  the  walls  of  the  sinus  should  be  freshened  and 
sutured. 

Its  differentiation  from  persistent  ductus  omphalomesenterieus  has 
been  emphasized  above. 


192  DISEASES   OF    CHILDREN 

MALFORMATIONS  OF  THE  GENITOURINARY  ORGANS 

Congenital  Abnormalities  of  the  Kidneys 

The  kidneys,  like  all  other  parts  of  the  body,  are  subject  to  defec- 
tive embryonic  development.  They  may  be  abnormal  in  size,  shape 
(horseshoe),  and  number.  This  is  of  clinical  importance,  since  mal- 
formed kidneys  are  more  easily  affected  by  disease,  especially  tuber- 
culosis, than  normal  organs.  Congenital  absence  of  one  kidney  has 
been  observed  once  in  about  4,000  autopsies.  Furthermore,  it  is  usually 
found  that  whenever  one  kidney  is  absent,  the  other  one  is  in  a  more  or 
less  diseased  condition,  chiefly  greatly  hypertrophied.  Congenital  dis- 
placement of  the  kidney  (both  kidneys  on  one  side;  in  front  of  the 
vertebral  column ;  low  down  in>  the  pelvis)  is  very  apt  to  cause  many 
diagnostic  errors. 

Malformations  of  the  Ureters 

Abnormal  ureteral  openings,  as  to  size  and  position,  are  of  great 
clinical  significance.  In  the  male  the  ureter  may  terminate  into  the 
sphincter  of  the  bladder,  the  prostatic  portion  of  the  urethra,  or  in 
the  seminal  vesicles,  and  by  interference  with  the  flow  of  urine  give 
rise  to  dilatation  of  the  ureter  and  renal  pelvis  and  atrophy  of  the  renal 
parenchyma.  In  the  female  the  ureter  may  end  in  the  sphincter  of 
the  bladder,  in  the  urethra,  or  in  the  vagina.  More  serious  than  mis- 
placement is  absence  or  atresia  of  the  ureter.  Either  one  of  these  latter 
conditions  invariably  produces  hydronephrosis,  compelling  extirpation 
of  the  affected  kidney.  Double  ureter,  if  free  from  any  other  anomaly, 
is  not  attended  by  any  pathologic  phenomena. 

Malformations  of  the  Bladder 

Ectopia  Vesicae  Congenita,  Cleft  Bladder,  Fissure  of  the  Bladder, 
Extrophy  Vesicae. — Cleft  bladder  arises  from  arrest  of  development  of 
the  anterior  walls  of  the  bladder  and  abdomen,  and  often  also  of  the 
symphysis.  It  may  be  partial  or  complete.  In  the  complete  variety 
the  posterior  vesical  wall  protrudes  as  a  round,  moist,  bright-red  tu- 
mor, through  a  gap  in  the  abdominal  wall,  situated  in  the  median 
line  between  the  umbilicus  and  the  urethra.  The  mass  is  marked  by 
two  small  tubercles  on  both  sides — the  orifices  of  the  urethra — from 
which  the  urine  dribbles  continuously.  In  the  male  this  is  associated 
with  epispadias  of  the  rudimentary  penis;  in  the  female  the  clitoris 
is  clefted,  the  labia  are  widely  separated,  and  the  urethra  and  vagina 
more  or  less  defective.  Eversion  of  the  bladder  is  often  complicated 
also  by  other  malformations  of  the  body,   and  in  the  majority   of 


CONGENITAL    MALFORMATIONS  193 

instances  leads  to  early  death.  Partial  ectopia  vesicte  offers  a  more 
favorable  prognosis,  particularly  if  a  plastic  operation  is  resorted  to 
early.  Temporary  relief  may  be  obtained  from  a  suitable  urinal  held 
in  place  by  means  of  a  truss. 

Malformations  of  the  Urethra,  Prepuce,  Testicles,  and.  Vagina 

Atresia  Urethrse. — Total  atresi-a  vrethrce  is  a  rare  malformation. 
When  it  does  occur,  it  is  usually  epithelial  in  nature  or  at  most  mem- 
branous. In  the  former  instance  the  atresia  promptly  yields  to  pres- 
sure with  the  tip  of  a  sound;  in  the  latter,  to  a  small  incision  and 
dilatation  by  means  of  a  small,  blunt  silver  probe. 

Complete  absence  of  the  urethra  is  extraordinarily  rare. 

Congenital  stenoses  are  not  rarely  found  along  the  urethra,  and  if 
presenting  no  distinct  hindrance  to  urination  are  frequently  over- 
looked. 

In  cases  of  marked  urethral  stenosis,  the  still  patent  urachus  often 
permits  the  escape  of  urine  through  its  fistulous  tract  running  from  the 
bladder  to  the  umbilicus. 

Misplacement  of  the  Urethral  Opening  (Epispadias,  Hypospadias). — 
The  urethral  opening  may  be  situated  on  the  upper  part  of  the  penis 
(epispadias)  or  at  its  inferior  aspect  (hypospadias).  The  latter  ab- 
normality is  more  frequent  than  the  former.  Both  conditions  are  pro- 
ductive of  more  or  less  disturbance  of  urination  (incontinence  in 
epispadias,  dysuria  in  hypospadias),  secondary  /intertrigo,  erosion 
and  ulceration  of  the  genitalia  from  the  effects  of  the  irritating  urine, 
and  later  in  life  interference  with  virility. 

Pronounced  hypospadias  (perineoscrotal)  closely  resembles  hermaph- 
roditism, and,  when  associated  with  retention  of  the  testicles,  it  may 
be  impossible  to  determine  the  sex  of  the  infant. 

Except  in  the  very  mildest  cases  early  operative  interference  is  in- 
dispensable. 

Congenital  Phimosis 

A  moderate  degree  of  adherence  of  the  prepuce  to  the  glans  penis  is 
physiologic  in  the  newborn.  Ordinarily  the  adhesions  disappear  spon- 
taneously in  the  course  of  time.  In  some  cases,  however,  the  prepuce 
remains  adherent  and  stenosed  at  its  orifice  so  that  the  glans  cannot 
pass  through.  In  consequence  there  is  more  or  less  retention  of  urine 
between  glans  and  prepuce  (particularly  if  the  latter  is  elongated  or 
hypertrophied),  infection  and  decomposition  of  the  sebaceous  secre- 


194  DISEASES   OF    CHILDREN 

tion  (smegma)  and  secondary  inflammation  of  the  penis  and  adjacent 
structures. 

In  the  presence  of  inflammation  urination  is  difficult  and  very  pain- 
ful, the  infant  cries,  presses  and  strains  (in  predisposed  children  often 
the  cause  of  hydrocele,  hernias  and  prolapsus  recti),  or,  fearing  pain, 
retains  the  urine  for  many  hours,  a  habit  which  is  apt  to  give  rise  to 
cystitis,  pyelitis,  and  even  uremic  convulsions. 

Phimosis  frequently  forms  also  the  cause  of  enuresis,  priapism,  mas- 
turbation, and  a  number  of  more  or  less  reflex  nervous  phenomena. 

In  mild  cases  of  phimosis  the  prepuce  should  frequently  be  pushed 
back  and  forth  and  the  retained  smegma  removed.  When  the  ad- 
hesions are  very  firm  they  may  be  broken  up  with  the  aid  of  a  dull 
probe  and  kept  loose  by  daily  retraction  of  the  foreskin  and  application 
of  an  antiseptic  cooling  lotion  such  as  lead  water  or  a  2  per  cent  solu- 
tion of  aluminum  acetotartrate.  In  this  manner  good  results  are  ob- 
tained within  a  few  days. 

When  the  preputial  stenosis  is  the  predominating  trou})le,  slight 
nicking  of  the  preputial  ring  with  scissors  (laterally,  above,  and  be- 
low), followed,  as  before,  by  loosening  of  the  adhesions,  daily  preputial 
retraction  and  local  antiphlogosis,  is  all  that  will  be  necessary  to  effect 
a  permanent  cure.  This  procedure  is  at  all  times  preferable  to  cir- 
cumcision, except  in  cases  of  phimosis  associated  with  elongated  or 
greatly  hypertrophied  foreskin  and  severe  inflammation. 

Circumcision,  when  indicated,  should  be  performed  under  very 
careful  aseptic  precautions,  preferably  under  general  anesthesia.  The 
surgeon  grasps  the  prepuce  between  the  thumb  and  index  finger,  ex- 
erting sufficient  traction  to  draw  it  from  the  glans  penis,  puts  over  it 
a  shield  or  forceps  just  in  front  of  the  glans,  and  with  scissors  or 
knife  removes  the  distal,  superfluous  portion  of  the  prepuce.  He  next 
seizes  the  inner  layer  of  the  prepuce,  which  still  covers  the  glans,  with 
a  thumb  forceps  and  with  the  aid  of  scissors  cuts  it  so  far  backward 
as  to  enable  him  fully  to  expose  the  glans  and  bring  the  edges  of 
both  preputial  layers  in  apposition  by  a  fine  continuous  suture.  The 
dressing  should  consist  of  sterile  gauze  (not  medicated!  danger  of  in- 
toxication). Numerous  accidents  have  been  reported  as  the  result 
of  circumcision,  but  all,  except  uncontrollable  hemorrhage  in  the 
hemophilic,  are  preventable.  In  such  hemorrhage  the  actual  cautery 
should  be  resorted  to  without  delay  and  use  all  other  therapeutic 
measures  as  recommended  for  melena  (p.  230)  and  hemophilia  (p.  553). 
Milder  hemorrhages  will  often  yield  to  firm  compression  of  the  penis 
with  a  hard  catheter  in  the  urethral  canal. 


CONGENITAL   MALFORMATIONS  195 

Cryptorchidism 

(Undescended  Testicle) 

Normally  the  testicles  descend  into  the  scrotum  by  the  end  of  fetal 
life.  In  the  event  of  arrested  development  or  malformation  of  the 
canal  of  Nuck,  of  a  constriction  of  the  inguinal  ring,  and  malfor- 
mation of  the  testis,  epididymis,  or  the  vas  deferens,  etc.,  one  (monor- 
chidism)  or  both  (cryptorchidism)  testicles  are  not  infrequently  re- 
tained in  the  abdominal  cavity,  at  the  inguinal  ring,  or  at  the  upper 
portion  of  the  scrotum.  More  rarely  the  testicles  become  displaced, 
and  through  a  false  passage  emerge  either  at  the  crural  arch  (crural 
testicle;  under  the  fold  of  skin  between  the  thigh  and  scrotum  (scro- 
tofemoral  testicle)  ;  or  behind  the  scrotum  (perineal  testicle). 

In  the  majority  of  instances  an  undescended  testicle  is  free  from 
any  serious  consequences,  and  reaches  its  normal  position  spontane- 
ously within  the  first  few  years  of  life.  Occasionally,  however,  it  may 
become  impacted  at  the  inguinal  canal,  giving'  rise  to  excruciating 
pain  and  inflammatory  symptoms;  if  associated  with  hernia,  strangu- 
lation may  take  place  in  both  structures  at  the  same  time;  it  may  cause 
atrophy  in  the  genitalia ;  it  may  be  the  seat  of  malignant  degeneration, 
and  finally,  it  may  be  productive  of  a  number  of  reflex  phenomena 
(epilepsy?). 

Cryptorchidism  should  not  be  confounded  with  anorcJiidisni  or  ab- 
sence from  the  body  of  both  testicles  (this  is  usually  associated  with 
rudimentary  penis  and,  later,  absence  of  spermatic  secretion),  or  with 
ascent  of  the  testicles  from  contraction  of  the  scrotum  (they  descend 
with  relaxation  of  the  scrotum). 

Expectant  plan  of  treatment  is  followed  up  to  puberty  in  the  ab- 
sence of  complications.  A  capsular  truss  should  be  worn  in  cases  of 
misplacement.  Gentle  massage  is  useful.  Orchidopexy  and  other 
surgical  procedures  should  be  instituted  as  indications  arise.  Speedy 
operation  in  case  of  strangulation. 

Hydrocele 

It  is  a  common  affection  of  early  infancy  and  most  frequently  con- 
genital in  nature.  Varying  with  the  seat  of  the  accumulation  of  the 
abnormal  quantity  of  serous  fluid,  we  distinguish  the  following  kinds: 

1.  Hydrocele  Tunicce  Vaginalis. — This  is  a  unilateral,  oval,  smooth, 
translucent,  more  or  less  tense,  fluctuating  swelling,  which  appears  first 
at  the  lower  part  of  the  scrotum,  and  gradually  rises  up  to  the  abdom- 
inal ring.    Posteriorly  to  the  hydrocele  usually  lies  the  testicle. 


196 


DISEASES   OF    CHILDREN 


2.  Hydrocele  Funicili  Spermatid  (Hydrocele  of  the  Cord). — This 
form  resembles  the  former;  except  that  the  testicle  usually  lies  at  the 
bottom  of  the  scrotum  and  is  distinctly  separated  from  the  hydrocele 
by  a  constriction.  It  is  sometimes  made  up  of  several  small  cysts  simulat- 
ing a  string  of  beads. 

3.  Hydrocele  Vaginalis  Communicans  C Congenital  Hydrocele"). — 
This  form  occurs  when  the  tunica  vaginalis  preserves  its  communi- 
cation with  the  abdominal  cavity  and  becomes  filled  with  serum,  form- 


Fig.  43. — Congenital  hydrocele  communicans. 

ing  a  cylindrical  tumor,  extending  to  and  through  the  abdominal  ring. 
It  is  often  associated  with  hernia  (hydrocele  hernialis).  As  the  con- 
tents of  both  are  reducible  on  pressure  the  differential  diagnosis  be- 
tween congenital  hernia  and  hydrocele  vaginalis  communicans  is  some- 
times difficult.  In  hydrocele,  however,  the  return  of  fluid  to  the  peri- 
toneal cavity  occurs  without  intestinal  gurgling — the  reverse  being 
the  case  in  congenital  hernia. 


CONGENITAL    MALFORMATIONS  197 

Hydrocele  often  disappears  spontaneously,  especially  after  removal 
of  reflex  irritation,  e.  g.,  phimosis.  If  it  persists,  we  employ  local  coun- 
terirritation  (painting  with  tincture  of  iodine  or  mercury  ointment),  or 
aspiration,  if  the  hydrocele  enlarges.  The  latter  procedure  may  be 
followed  by  the  injection  of  a  few  drops  of  tincture  of  iodine  or 
carbolic  acid  and  alcohol.  Absorption  of  the  fluid  is  hastened  by 
a  few  large  doses  of  potassium  iodide.  In  hydrocele  eommunicans  a 
truss  should  be  worn  to  prevent  hernia.  The  pressure  exerted  will  often 
obliterate  the  inguinal  portion  of  the  vaginal  process,  and  also  cure  the 
hernia,  if  present. 

If  the  aforementioned  palliative  and  curative  measures  fail — which 
is  rarely  the  case — a  radical  operation  becomes  necessary. 

Atresia  Vulvae.— Atresia  vulvae  consists  chiefly  of  a  cellular  adhe- 
sion of  the  labia  minora,  and  may  be  partial  or  complete.  In  total  atre- 
sia vulvae  there  is  anuria,  with  its  secondary  symptoms,  necessitating 
immediate  attention,  i.  e.,  forcible  separation  of  the  labia  with  the  fingers 
or  with  the  aid  of  a  dull  probe  or  scalpel.  In  partial  atresia  separation 
of  the  labia  occurs  spontaneously. 

Atresia  Vaginae  Hymenalis  (Imperforate  Hymen). — This  congenital 
malformation  usually  escapes  observation  until  puberty,  when  partial 
or  total  retention  of  the  menstrual  flow  gives  rise  to  local  and  general 
disturbances. 

Incision  and  packing  wath  iodoform  gauze  readily  remedies  the 
trouble. 

Atresia  Vaginae. — Like  the  aforementioned  malformation,  narrowing 
or  complete  closure  of  the  vagina  is  not  detected  till  after  puberty. 
Total  atresia  vaginae  is  usually  associated  with  absence  of  the  uterus. 
This  should  always  be  borne  in  mind  before  resorting  to  operative  pro- 
cedures for  the  relief  of  the  atresia. 

CONGENITAL  MALFORMATIONS  OF  THE  VERTEBRAL  COLUMN 

(Including  Those  of  the  Sacrum  and  Coccyx) 
Spina  Bifida  or  Hernia  of  the  Cord 

Meningocele  Spinalis,  Myelocystocele,  Myelomeningocele. — Analo- 
gous to  hernia  of  the  brain  (see  'X^ephalocele"),  that  of  the  cord  also  is 
divisible  in  three  principal  groups :  Meningocele  spinalis,  myelocystocele, 
and  myelomeningocele. 

{a)  Meningocele  Spinalis. — ^Meningocele  spinalis  is  a  protrusion  of 
the  pia  mater  without  participation  of  the  spinal  cord.  It  is  filled  with 
cerebrospinal  fluid,  translucent,  often  pedunculated  and  may  reach  the 
size  of  a  child's  head.  It  is  covered  by  normal  skin.  Paralysis  is  rare. 
Pressure  on  the  tumor  produces  bulging  of  the  fontanelles  and  spasms. 


198 


DISEASES   OF    CHILDREN 


(&)  Myelocystocele. — Myelocystocele  is  situated  on  a  broad  base  and 
is  readily  replaceable  on  pressure.  The  covering  skin  is  greatly  distended 
but  normal  in  color.  Palpation  reveals  that  the  tumor  consists  of  solid 
masses  in  addition  to  fluid.  It  is  frequently  associated  with  hydroceph- 
alus and  accompanied  by  motor  and  sensory  disturbances. 

(c)  Myelovie7iingocele.^-Mye\omemngoce\e  is  a  pear-shaped  or  spheri- 
cal fluctuating,  tense,  broad  or  pedunculated  tumor  the  size  of  a  walnut 
to  that  of  a  child's  head.  Its  covering  skin  is  bluish,  very  thin  and  tra- 
versed by  numerous  blood  vessels.  It  is  composed  of  cord  substance 
and  its  membranes,  and  forms  a  true  hernial  protrusion  through  a  cleft 
in  the  vertebral  column.  The  cleft  and  to  some  extent  also  the  hernial 
orifice  can  often  be  felt  at  the  base  of  the  tumor.  Myelomeningocele  is 
the  most  frequent  variety'  of  spina  bifida  and  gives  rise  to  marked  motor 
and  sensory  paralyses. 


Fig.    44. — Myelocystocele.      Note    funnel-shaped    evorsion    of    the    rectum    owing    to 
paralysis  of  the  levator  and  sphincter  ani. 

Almost  all  forms  of  spina  bifida  are  associated  with  hypertrichosis  of 
the  surrounding  skin.  This  is  especially  pronounced,  and  indeed,  often 
forming  the  only  outward  sign  of  deformity,  in  spina  bifida  occulta  (a 
meningocele  usually  at  the  sacrolumbar  region  hidden  under  masses  of 
fat).  The  hair  is  usually  so  arranged  as  to  form  a  crown  over  the  center 
of  the  defect.  When  well  developed  it  may  resemble  a  tail.  Apart  from 
the  malformation  the  condition  of  most'  children  at  first  is  perfectly 
normal.  As  the  tumor  enlarges  the  results  of  the  pressure  on  the  cord 
or  the  Cauda  equina  gradually  appear.  The  symptoms  vary  with  the  de- 
gree of  involvement  of  the  spinal  cord;  they  are,  therefore,  most  pro- 
nounced in  myelomeningocele  sacrolumbalis.  Here  we  have  motor  and 
sensory  paralyses  of  the  legs,  of  the  rectum,  bladder,  and  the  perineal 


CONGENITAL    MALFORMATIONS 


199 


muscles,  convulsions  and  trophic  disturbances.  In  less  severe  cases,  the 
paralysis  may  be  limited  to  the  legs  only.  Several  years  ago  (Med. 
Rec,  New  York,  Jan.  6,  1912)  I  called  attention  to  persistent  incon- 
tinence of  urine  forming  a  characteristic  symptom  of  spina  bifida 
occulta. 

Bearing  in  mind  the  characteristic  symptomatology  of  spina  bifida, 
i.  e.,  a  more  or  less  translucent,  compressible,  barely  movable,  thinly 


Fig.  45. — Spiua  bifida  occulta  in  a  boy  eight  years  old.     This  condition  was  associ- 
ated with  incontinence  of  urine. 


covered  tumor,  in  the  majority  of  instances  associated  with  paralyses, 
there  ought  to  be  no  difficulty  in  differentiating  it  from  sacrolumbar 
neoplasms.  In  cases  of  doubt  the  diagnosis  may  often  be  cleared  up 
by  exploratory  puncture  and  radiographic  examination  (the  latter  show- 
ing a  vertebral  cleft). 

Spina  bifida  may  sometimes  escape  notice  when  it  is  surrounded  by 
a  solid  tumor. 

The  majority  of  children  with  marked  spina  bifida  die  when  very 


200  DISEASES   OF    CHILDREN 

young,  often  during  birth,  owing  to  rupture  of  the  tumor  and  shock 
following  rapid  escape  of  the  cerebrospinal  fluid.  Most  of  those  who 
survive  succumb  later  from  rupture  of  the  sac  and  subsequent  infection 
and  purulent  meningitis;  from  gangrene  and  ulceration  of  the  skin 
with  subsequent  sepsis;  and  finally,  from  intercurrent  diseases  and 
marasmus.  Simple  meningocele  gives  the  best  prognosis  if  recog- 
nized early  and  jDrotected  from  external  insults  by  a  suitable  pad  or 
apparatus. 

This  palliative  method  of  treatment  should  always  be  tried  in  cases 
of  spina  bifida  which  project  very  slightly  and  are  covered  by  nor- 
mal, well-nourished  skin.  Aspiration  of  the  hernial  sac  is  useful  to 
relieve  the  symptoms  of  compression  and  to  lessen  the  danger  of  spon- 
taneous rupture.  Aspiration  may  be  followed  by  injection  of  iodine  or 
preferably  iodine-gelatin.  In  selected  cases  it  may  prove  of  perma- 
nent benefit. 

A  radical  operation  is  the  ideal  procedure  in  suitable  cases.  How- 
ever, extensive  paralyses,  severe  irreparable  malformations  elsewhere, 
hydrocephalus,  and  grave  systemic  affections  are  contraindications 
to  operation.  In  such  cases  palliative  and  symptomatic  methods  of 
treatment  are  indicated. 

Congenital  Sacral  Tumors 

Closely  related  to  and  frequently  associated  with  spina  bifida  {q.  v.) 
are  congenital  sacrococcygeal  tumors.    They  may  be  classified  as  follows: 

1.  Doiihle  Formations — 

(a.)  Complete — two  fully  formed  individuals  grown  together 
at  the  buttocks. 

(&)  Incom,plete  or  parasitic  form^ations — one  or  several  rudi- 
mentary portions  of  the  body  attached  to  the  buttocks  of 
a  fully  formed  individual. 

2.  Sacral  Hygromas. — Single  or  multiple  cysts,  attached  by  a  broad 

base  to  the  dorsal  surface  of  the  sacrum.     They  are  sometimes 
associated  with  spinal  hernia, 

3,  Tumores  Coccygei. — Neoplasms  attached  to  the  anterior  surface 

of  the  sacrum  and  coccyx.  The  tumors  are  composed  of  fibrous 
or  granular  masses  generally  of  sarcomatous  nature,  sometimes 
of  fat,  cartilage,  or  bone.  Occasionally  they  involve  the  spinal 
canal,  or  surround  a  spinal  dural  protrusion  (spina  bifida). 
They  never  extend  above  the  lower  border  of  the  gluteus,  but 
spread  toward  the  pelvis  and  between  the  legs  of  the  child, 

4,  Caudal  Formations — 

(a)  Complete  tails,  manifested  by  an  actual  increase  in  the 
number  of  coccygeal  vertebrse. 


CONGENITAL    MALFORMATIONS  -^    '        '    '    ^^     201 

(b)  Imperfect  tails,  enlargement  of  vertebral  column  by  rudi- 
mentary tissue. 
But  few  children  born  with  coccygeal  tumors  live  beyond  the  age  of 
one  year.     As  the  tumors  enlarge,  the  infants  succumb  to  progressive 
cachexia  and  exhaustion. 

As  a  rule,  sacral  tumors  do  not  interfere  with  the  life  of  the  child 
if  suitable  protection  is  furnished  against  vulnerability  of  the  tumor 
and  secondary  infection.  In  some  selected  cases  (see  "Spina  Bifida") 
perfect  results  are  often  obtained  by  skillful  surgical  measures. 

MALFORMATIONS  OF  THE  EXTREMITIES  AND  HIP 

Of  the  numerous  malformations  of  the  extremities  {e.g.,  complete 
absence;  spontaneous  partial  amputations;  fractures;  supernumerary 
fingers  and  toes,  etc.)  but  few  are  of  interest  to  generar  practitioners — 
namely,  congenital  dislocation  of  the  hip  and  club  foot.  As  these  ab- 
normalities are  apt  to  be  confounded  with  similar  acquired  affections, 
they  will  receive  special  consideration, 

Luxatio  Coxae  Congenita 

(Congenital  Dislocation  of  the  Hip) 

The  dislocation  may  be  unilateral  or  bilateral.  The  acetabulum  is 
rudimentary  in  form,  and  the  head  of  the  femur  rests  either  above  it, 
above  and  to  the  outer  side,  or  above  and  behind  it  upon  the  ilium,  some- 
times immediately  at  the  side  of  the  great  sciatic  notch.  If  one  leg  is 
displaced  it  is  shorter  than  the  other,  giving  rise  to  distinct  limping. 
If  both  sides  are  affected  the  gait  is  wobbling — "duck  gait."  As  a  result 
of  this  anomaly  the  buttocks  project  prominently  backward  while  the 
spine  is  either  thrown  forward'  (lordosis,  in  bilateral)  or  tilted  sideways 
(scoliosis,  in  unilateral  dislocation).  The  differential  diagnosis  between 
this  condition  and  rachitis  and  coxa  vara  is  best  established  with  the  aid 
of  the  x-rays  which  show  the  abnormal  position  of  the  head  of  the  fe- 
mur. If  the  malformation  is  detected  early,  (in  a  certain  number  of 
cases  the  dislocation  is  acquired  as  a  result  of  septic  arthritis  in  the 
newborn)  it  may  be  corrected  either  by  opening  the  joint,  replacement 
and  fixation  of  the  head  of  the  femur  in  the  artificially  deepened  ace- 
tabulum, or  by  bloodless  forcible  reduction  of  the  deformity  and  fixation 
of  the  head  of  the  femur  in  the  acetabulum  by  prolonged  use  of  plaster- 
of -Paris  bandages  (Lorenz's  operation).  For  details  of  treatment  the 
reader  is  referred  to  textbooks  on  orthopedic  surgery. 


202  ^  ^ 


DISEASES   OF   CHILDREN 


Talipes 

(Club  foot) 

1.  Talipes  varus,  inversion  of  the  foot,  so  that  its  sole  faces  the  other 
foot.    This  is  the  most  common  of  the  congenital  forms. 

2.  Talipes  valgus,  flat-foot,  effacement  of  the  arch. 


Fig.   46. — Bilateral  club  feet  in  father  and  three  children.      (After  Joachimsthal.) 

3.  Talipes  equinus,  lowering  of  the  anterior  part  of  the  foot,  the  child 
steps  on  his  toes. 

4.  Talipes  calcaneus,  elevation  of  anterior  part  of  the  foot,  heel  alone 
touching  the  ground. 

Compound  forms  may  be  produced  by  combination  of  the  different 
varieties. 

The  diagnosis  of  the  type  of  club  foot  can  readily  be  made  by  inspec- 
tion; it  is  sometimes  difficult,  however,  to  differentiate  the  congenital 
from  the  acquired  forms,  e.  g.,  rachitic  or  paralytic  club  foot.    In  rickets 


CONGENITAL  MALFORMATIONS 


203 


the  distortion  of  the  feet  is  generally  associated  with  other  pathogno- 
monic symptoms  of  rickets  and  is  gradual  in  development.  In  paralytic 
club  foot  {e.  g.,  poliomyelitis)  the  limb  is  wasted,  flabby  and  cold  and 
there  is  a  history  of  postnatal,  gradual  appearance  often  in  association 
with  other  paralytic  deformities. 

Congenital  club  foot  is  being  attributed  to  various  causes,  but  is  prob- 
ably due  to  some  mechanical  interference  with  the  normal  development 
of  the  joints,  ligaments  or  tendon  insertions. 


Fig.  47. — Same  case  as  Fig.  44  showing  also  congenital  club  foot. 

Treatment  of  Club  Foot  by  General  Practitioner. — Oettingen  re- 
marks that  during  the  2,000  years  of  experiences  with  club  foot,  the 
important  part  played  by  the  knee  in  the  correction  has  been  almost 
entirely  overlooked.  The  deformity  develops  with  the  knee  flexed  to 
the  utmost,  and  it  should  be  flexed  at  a  right  angle  in  the  immobiliza- 
tion. This  has  the  great  advantage  that  the  sole  can  be  held  in  proper 
position  by  traction  on  the  J^nee.  Treatment  should  commence  the 
moment  the  child  is  first  presented  to  the  physician,  even  if  it  is 
only  one  day  old.  No  anesthesia  is  required,  merely  a  stout  twilled 
cotton  flannel  bandage  about  4  or  5  cm.  wide.  The  bandage  is  passed 
first  around  the  foot,  after  the  foot  and  thigh,  just  above  the  knee,  have 
been  smeared  with  a  soft  solution  of  mastic  which  glues  the  fuzzy 
stuff  firmly  to  the  skin.  The  bandage  starts  at  the  little  toe  and  is 
wound  around  the  foot  and  then  passed  from  the  little  toe  over  the 
knee  and  is  then  brought  around  and  across  the  front  of  the  leg  to  the 
inner  aspect  of  the  foot,  forming  thus  a  figure-of-eight  bandage.     Be- 


204  DISEASES   OF    CHILDREN 

fore  applying  the  bandage  the  physician  should  manipulate  the  foot 
to  bring  it  with  maximal  outward  rotation  of  the  leg  into  its  normal 
position,  watching  the  clock  to  see  that  he  does  not  take  less  than 
five  minutes  to  accomplish  this.  During  the  application  of  the  bandage 
the  assistant  holds  the  thigh  with  one  hand  and  the  middle  toe  of  the 
foot  with  the  other,  not  releasing  it  until  bandaging  is  completed.  By 
this  means  the  sole  of  the  foot  is  held  in  correct  position  supported 
by  the  thigh,  the  bandage  holding  the  foot  in  pronation,  outward  rota- 
tion, abduction  and  dorsal  flexion.  It  is  impossible  for  the  foot  to  slide 
back  into  its  old  position.  This  bandage  leaves  free  the  entire  thigh, 
the  under  part  of  the  knee,  and  the  entire  inward  aspect  of  the  leg 
and  ankle,  with  a  certain  possibility  for  movement  in  all  the  joints. 
These  are  all  immense  advantages.  The  child  is  allowed  to  go  home 
for  two  days,  and  can  be  bathed  if  the  leg  is  held  up  out  of  the  water. 
After  two  days  the  physician  removes  the  bandage,  washes  the  leg 
with  warm  water  and  soap,  and  massages  the  leg  for  a  few  minutes. 
A  bandage  is  then  applied,  which  is  left  for  five  days,  and  is  then 
removed  for  an  interval  of  four  days.  In  the  same  way  three  more 
bandages  are  applied,  each  for  a  week.  By  the  end  of  the  fourth  week 
the  foot  is  in  normal  position,  ready  for  the  after-treatment.  So  far, 
the  mother  is  not  allowed  to  massage  or  work  on  the  foot,  but  now  she 
is  taught  to  massage  three  or  four  times  a  day,  seizing  the  leg  above 
the  malleolus,  the  sole  toward  her  as  she  sits  or  stands  in  front  of  the 
reclining  child.  With  the  middle  finger  of  the  other  hand  on  the  little 
toe  of  the  foot,  she  strokes  the  sole  away  from  her.  This  one  simple 
movement  combines  the  four  compensating  elements  for  club  foot,  con- 
tinuing the  pronation,  extension,  abduction,  and  outward  rotation 
of  both  foot  and  leg.  With  older  children  a  rubber  strap  is  applied 
afterward,  passing  around  the  foot  and  knee  like  the  other,  with  a 
buckle  to  keep  it  fast,  tied  with  tape  to  keep  if  from  slipping  off  the 
knee.  Complicated  and  neglected  cases  of  club  foot,  of  course,  require 
surgical  therapeutic  measures. 

CONGENITAL  AFFECTIONS  OF  THE  MUSCLES  AND  BONES 

Amyatonia  Congenita 

(Myatonia  Congenita,  Oppenheim) 

Amyatonia  congenita  is  characterized  by  general  flaccidity  of  the 
muscles,  especially  of  the  lower  extremities  and  in  a  slighter  degree 
of  the  arms.  The  neck,  cranial  nerves  and  diaphragm  are  usually 
normal.  Intelligence  is  occasionally  deficient.  There  is  no  atrophy, 
but  the  patellar  reflexes  are  either  diminished  or  lost.  As  the  af- 
fection seems  to  be  due  to  delayed  development  of  the  musculature,  it 


CONGENITAL    MALFORMATIONS 


205 


generally  improves,  particularly  if  assisted  by  massage,  baths  and  elec- 
tricity, and  general  tonic  treatment.  In  a  case  reported  by  J.  B.  Holmes* 
postmortem  examination  revealed  a  relatively  large  spinal  cord  with  the 
anterior  roots  diminished  in  size,  as  compared  with  the  posterior  roots. 

Myotonia  Congenita 

(Thomsen's  Disease) 

This  is  a  rare,  probably  hereditary,  affection  of  the  muscular  sys- 
tem, characterized  by  sudden  spasm  and  rigidity  of  individual  or 
groups  of  muscles,  especially  when  the  patient  begins  a  voluntary 
movement,  e.  g.,  arising  from  a  certain  posture,  clasping  hands,  etc. 


Fig.  48. — Osteogenesis  Imperfecta.  Every  long  bone  of  the  body  was  repeatedly 
fractured.  The  child  finally  died  at  the  age  of  two  and  a  half  years  from  cerebral 
hemorrhage  resulting  from  a  slight  fall  upon  the  head.  (Courtesy  of  Dr.  J.  L. 
Rubinstein.) 

Similar  tonic  contractions  occur  from  the  effects  of  a  blow  upon  a 
muscle;  and  the  application  of  a  strong  (20  to  25  milliamperes)  gal- 
vanic current  produces  certain  Avave-like  muscle  contractions  which 
move  from  the  area  of  the  cathode  to  that  of  the  anode.  Although 
often  appearing  in  early  infancj',  the  disease  does  not  endanger  life  or 
health.    Warm  baths  and  massage  may  prove  of  benefit. 

Osteogenesis  Imperfecta 

(Fragilitas  Ossium  Idiopathica) 

This  rare,  congenital  bone  affection  of  obscure  origin  is  characterized 
anatomically  by  the  unusual  persistence  of  the   interstitial   cartilagi- 


•Am.  Jour.  Dis.   Child.,  November,   1920. 


206  •  DISEASES  OP   CHILDREN 

nous  substance  and  great  deficiency  of  osseous  elements  and  lime  salts 
in  the  primary  zone  of  calcification.  It  involves  all  the  bones  of  the 
body.  They  are  soft  and  thin  and  readily  bend  and  break  on  the  slight- 
est manipulation ;  hence  the  frequency  of  several  fractures  during  de- 
livery of  the  baby.  Those  who  survive  early  infancy,  often  succumb 
to  fractures  of  the  head,  spine  or  ribs  v^^hen  they  begin  to  stand  or 
walk.  Cases  reaching  adolescence,  however,  are  on  record.  As  frac- 
tures of  the  long  bones  are  not  rarely  met  with  in  congenital  syphilis, 
osteogenesis  imperfecta  is  apt  to  be  mistaken  for  the  former  disease. 
In  syphilis^  however,  we  have  several  other  characteristic  signs,  in- 
cluding positive  Wassermann  reaction,  which  are  absent  in  osteogene- 
sis imperfecta.    For  its  differentiation  from  rachitis,  see  p.  511. 

Treatment. — Avoidance  of  traumatism  and  attention  to  the  general 
health  of  the  baby.  Phosphorus  preparations  and  cod  liver  oil  may  be 
tried,  especially  in  mild  cases.  As  the  thymus  is  not  rarely  found  at- 
rophied, thymus  treatment  is  worth  trying. 

Achondroplasia  (see  p.  512). 


CHAPTER  IV 
INJURIES  AND  DISEASES  OF  THE  NEWBORN 

I.  BIRTH  INJURIES 

Nature  in  its  infinite  wisdom  provides  a  more  or  less  large  quantity 
of  liquor  amnii  to  protect  the  fetus  in  utero  against  undue  pressure 
and  possible  injury.  If,  perchance,  the  amniotic  fluid  escapes  prema- 
turely, either  spontaneously  or  artificially,  the  fetus,  in  its  descent 
through  the  parturient  canal,  subjected  to  powerful  pressure  by  the 
maternal  structures  or  mechanical  manipulations,  sustains  a  number 
of  injuries  which  vary  in  severity  from  simple  external  bruising  to 
grave  compound  fractures  and  internal,  sometimes  fatal,  injuries. 

A.  Superficial  Structures 

Caput  Succedaneum 

Vertex  presentation  being  the  most  common  form  of  delivery,  the 
head  consequently  stands  the  brunt  of  the  injuries.  The  so-called 
caput  succedaneum  is  a  circumscribed  edema  of  the  scalp  and  consists 
of  a  serous  or  hemorrhagic  extravasation  into  the  subcutaneous  tis- 
sues of  the  scalp.  It  is  observed  immediately  after  birth  as  a  doughy, 
evenly  distributed,  variously  sized,  soft  tumor  which  disappears  spon- 
taneously by  absorption,  unless  infected  through  external  abrasions. 
In  the  latter  event  it  requires  surgical  treatment,  such  as  antiseptic 
dressings,  incision  and  drainage. 

Cephalhematoma 

More  serious  than  the  aforementioned  condition  is  hemorrhage  oc- 
curring between  the  pericranium  and  cranial  bones  in  the  form  of  a  cir- 
cumscribed, elastic,  distinctly  fluctuating,  painless  tumor,  situated 
upon  the  right  or  left  side  of  the  head  (sometimes  both  sides  are  af- 
fected). The  cephalhematoma  develops  gradually  within  the  first  few 
days  of  extrauterine  life,  and  owing  to  the  firm  attachment  of  the 
periosteum  to  the  edges  of  the  cranial  bones  along  the  sutures,  it  never 
extends  beyond  the  latter  or  over  the  fontanelle.  All  around  the  tu- 
mor a  hard,  bony  ridge  is  soon  (after  about  two  weeks)  detected, 
which  with  the  depressed  center  gives  a  sensation  somewhat  like  that  of 
a  depressed  fracture. 

207 


208  DISEASES   OF    CHILDREN 

Cephalhematoma  may  be  mistaken  for  caput  succedaneum,  which 
appears  immediately  postpartum  and  disappears  after  a  day  or  two ; 
for  subaponeurotic  or  subcutaneous  hemorrhages,  which  occur  some- 
times also  from  intrapartum  pressure,  but  extend  beyond  the  sutures; 
for  congenital  encephalocele,  which  lies  between  but  not  over  the 
bones,  pulsates,  enlarges,  on  crying  or  coughing,  and  can  be  partially 
reduced;  and,  finally,  for  vascular  tumors,  which  are  compressible  and 
free  from  a  bony  ridge. 

The  tumor  usually  disappears  spontaneously,  sometimes  requiring 
weeks  and  months  to  do  so.  If  suppuration  occurs,  it  calls  for  surgical 
interference. 

Hematoma  Stemocleidomastoidei 

Pathologically  akin  to  cephalhematoma  is  the  intrapartum  hemor- 
rhage which  takes  place  within  the  sheath  of  the  sternocleidomastoid 
muscle,  as  a  result  of  rupture  of  several  muscle  fibers  and  consecutive 
myositis. 

The  tumor  in  the  neck  is  generally  observed  a  few  weeks  after  birth, 
more  rarely  earlier,  by  noting  the  baby  holding  its  head  on  the  side. 
It  varies  in  size  from  that  of  a  hickory  nut  to  a  walnut.  It  is  at  first 
soft,  later  hard  and  cartilaginous  in  consistence.  Severe  hemorrhages 
may  give  rise  to  torticollis. 

This  condition  demands  perfect  rest  to  the  head,  cold  compresses 
for  the  relief  of  pain,  and  later  gentle  massage  to  promote  absorption 
of  the  tumor. 

Iln^.  kalii  iofl.  (U.  S.  P.)     I 

Adipis  lanae  aa  3  ii      8.0 

M.    ft.    Ung.  I 

S. :   To  be  applied  ^ith   gentle  massage  once  a  day. 

2.  Deep  Structures 

Birth  traumatism  is  not  always  limited  to  the  skin  and  muscles. 
Now  and  then  the  viscera  (the  lungs,  liver,  peritoneum,  etc.),  the  bones, 
the  peripheral  nerves,  the  meninges  and  brain  are  involved.  Fractures 
and  dislocations  are  not  rarely  observed,  especially  in  the  long  tubular 
bones  and  the  clavicle,  while  the  cranial  bones  are  often  badly  dis- 
placed (the  occipital  and  frontal  are  pushed  under  the  parietals),  fis- 
sured (see  ''Meningocele,"),  compressed  and  fractured,  giving  rise  to 
grave,  frequently  fatal,  intracranial  hemorrhages. 

Central  Birth  Paralysis 
Cerebral  Hemorrhage    Apoplexia  Neonatorum 
Usually  the  seat  of  the  hemorrhage  is  the  subarachnoid  space ;  often 
the  delicate  pia  mater;  sometimes  between  the  dura  and  arachnoid; 


INJURIES    AND   DISEASES   OF    THE   NEWBORN 


209 


more  rarely  between  the  raenino:e.s  of  the  cerebellum;  the  lateral  ven- 
tricles, and  exceptionally  the  brain  substance. 

According  to  Seitz  the  hemorrhage  is  the  result  of  rupture  of  the 
longitudinal  sinus  or  veins,  of  the  transverse  sinus  or  of  vessels  of  the 
chorioid  plexus. 


Fif.  49.— Method  of  insertion  oT  trocar  through  the  anterior  fontanel  to  reach  the 
ventricles.     (After  P.  Eavaut.) 


The  symptoms  differ  with  the  extent  and  seat  of  the  hemorrhage. 
For  several  hours  no  characteristic  sj-mptoms  may  be  evident.  How- 
ever, most  infants  are  born  asphyxiated.  The  majority  of  those  born 
alive  succumb  within  a  few  days  under  symptoms  of  asphyxia  and  ate- 


210 


DISEASES    OF    CHILDREN 


lectasis,  slow,  full,  irregular  pulse,  frequently  high  fever,  nystagmus, 
bulging  of  the  fontanelles,  sopor,  convulsions,  rigidity  and  paralysis. 
Those  few  who  survive,  often  at  an  early  age  or  later  present  the 
symptom-complex  of  cerebral  paralysis  (see  p.  601)  with  or  without 
idiocy. 

The  treatment  is  essentially  the  same  as  in  traumatic  cerebral  hemor- 
rhage in  older  children — principally  surgical.  (See  p.  604.)  An  at- 
tempt may  be  made  to  relieve  the  intracranial  pressure  by  lumbar 
puncture  or  aspiration  of  the  subdural  space.  Lumbar  puncture  is  al- 
ways worth  trying,  and  if  it  brings  blood,  which  is  often  the  case 
in  infratentorial  hemorrhage,  the  puncture  should  be  repeated  two  or 
three  times,*  each  time  withdrawing  from  5  c.c.  to  15  c.c.  Aspiration 
of  the  subdural  space  is  accomplished  by  introducing  a  trocar  almost 
parallel  with  the  surface  of  the  skull,  at  a  point  corresponding  with 
the  lateral  angle  of  the  anterior  fontanelle,  and  withdrawing  a  suffi- 
cient amount  of  blood  to  relieve  the  pressure  symptoms   (Fig.  49). 

F.  C.  Roddaf  suggests  the  subcutaneous  injection  of  25  c.c.  of  blood, 
if  the  patient's  blood  is  found  wanting  in  coagulability. 

Peripheral  Birth  Paralysis 
Facial  Palsy 

Facial  paralysis  in  the  newborn  is  usually  of  traumatic  origin  as  a 
result  of  pressure  exerted  upon  the  facial  nerve  by  the  obstetrical 


Fig.  50. — Obstetric  facial  paralysis  in  boy  fifteen  months  old,  which  failed  to  yield 

to  treatment. 


forceps  or  deformed  pelvis.     It  may  be  unilateral  or  bilateral.       It 
resembles  facial  paralysis  of  older  children  (see  p.  663)   except  that  it 


*H.  Vignes,  Progres  Med.,  No.  33,  1918,  J.  M.  Brady,  Jour.  Am.  Med.  Assn.,  Sept.  21,  1918. 
tjour.  Am.  Med.  Assn.,  Aug.  14,  1920. 


INJURIES   AND   DISEASES    OF    THE    NEWBORN 


211 


runs  a  milder  course.  Very  rarely  the  paralysis  is  permanent.  It  is 
important  to  differentiate  this  form  of  facial  paralysis  from  that  of 
central  origin.  In  the  latter  form,  as  a  rule,  other  portions  of  the 
body  are  involved,  while  the  orbicularis  palpebrarum  remains  free. 
The  so-called  congenital,  nontraumatic  facial  paralysis  is  probably 
syphilitic  in  nature. 

Brachial    Paralysis— Obstetrical    Paralysis— Duchenne-Erb    Paralysis 

In  mild  form  it  is  of  quite  frequent  occurrence.     In  typical  cases 
the  paralysis  is  usually  limited  (80  per  cent)  to  the  muscles  supplied 


Fig.  51. 


-Bilateral  obstetric  brachial  paralysis,  the  so-called  "Duchenne-Erb 
Paralysis ' '. 


by  the  brachial  plexus  composed  of  the  lower  four  cervical  nerves 
and  the  first  dorsal,  and  their  branches,  i.  e.,  the  deltoid,  biceps,  brach- 
ialis  anticus,  infraspinatus,  supinator  longus  and  the  supinator  brevis. 
The  arm  (rarely  both  sides  are  affected — from  reckless  instrumental 
manipulations)   hangs  motionless,  the  upper  arm  is  rotated  inward, 


212 


DISEASES   OF   CHILDREN 


the  forearm  is  pronated,  and  the  palm  of  the  hand  is  turned  backward 
and  outward  (Fig.  51).  The  Avrist  and  fing-er-joints  are  usually  only 
slightly  affected ;  sensibility  is  intact  and  electrical  reaction  diminished 
or  lost. 

Recovery  is  the  rule  in  mild  eases.  Those  lasting  over  three  months 
show  trophic  changes  in  the  affected  muscles,  especially  in  the  deltoid. 
The  prognosis  in  cases  of  brachial  paralysis  presenting  reaction  of  de- 
generation, is  doubtful. 


Fig.  52. — Obstetric  brachial  palsy:     Erb's  "upper  arm  type";  failed  to  respond  to 

treatment. 


Treatment. — After  keeping  the  affected  arm  perfectly  at  rest  for  two 
weeks,  the  faradic  or  galvanic  current  should  then  be  applied  daily, 
for  about  five  minutes  at  a  time,  until  muscular  power  has  been  re- 
stored. Gentle  massage  and  passive  motion  are  very  useful  as  a  proph- 
ylactic against  atrophy  and  contractures.  In  complete  rupture  of 
one  or  more  cords  of  the  brachial  plexus,  nerve  end-to-end  anastomo- 
sis and  tendon  transplantation  are  the  only  curative  means  at  our 
command.  Muscle  training  is  indicated  in  children  old  enough  to 
respond  to  suggestions. 


INJURIES    AND    DISEASES    OF    THE    NEWBORN  213 

II.  DISEASES  OF  THE  NEWBORN 
Feeble  Vitality  of  the  Newborn 

The  physician  is  often  confronted  by  a  group  of  clinical  phenomena 
in  the  newborn  which  may  briefly  be  designated  as  "feeble  vitality." 
It  is  a  clinical  entity  which,  though  greatly  at  variance  as  to  cause  and 
ultimate  course,  presents  at  birth  a  uniform  symptom-complex  and  de- 
mands a  more  or  less  uniform  mode  of  treatment. 

It  is  characterized  by  pronounced  respiratory  and  circulatory  dis- 
turbances, subnormal  temperature,  somnolence,  general  debility  with 
or  without  emaciation,  and  is  usually  associated  with  one  or  several 
presently  to  be  described  diseased  conditions. 

1.  Asphyxia  Neonatorum 

(Suspended  Animation) 

The  asphyxia  may  be  momentary,  or  last  several  minutes  up  to 
an  hour  or  longer.  Mild  forms  of  asphyxia  are  manifested  by  slight 
lividity  (asphyxia  livida)  of  the  face,  feeble  superficial  breathing,  and 
slow  and  weak  heart  beat.  If  the  asphyxia  is  allowed  to  continue, 
the  face  becomes  deeply  cyanosed  and  congested,  the  eyes  bulge, 
the  musculai*  tonus  and  cutaneous  sensibility  are  retarded,  the  umbili- 
cal cord  is  collapsed,  and  respiration  is  barely  perceptible.  Finally, 
the  infant  becomes  deathly  pale  (asphyxia  pallida),  the  muscular 
tonus  and  reflexes  are  lost,  the  heart  beat  is  scarcely  audible  and  res- 
piration ceases. 

Postmortem  examination  reveals  overdistention  of  the  right  ventri- 
cle of  the  heart;  cerebral,  pulmonary  and  hepatic  congestion;  in- 
creased fluidity  of  the  blood;  serosanguinolent  exudation  in  the  serous 
cavities;  accumulation  of  liquor  amnii,  blood  and  mucus  in  the  air  pas- 
sages, and  pulmonary  atelectasis. 

Prompt  and  prolonged  resuscitating  efforts  (Sylvester's,  Schultze's 
and  Laborde's)  are  usually  attended  by  favorable  results.  However, 
intracranial  hemorrhage  with  consecutive  mental  and  physical  defects 
are  not  infrequent  sequelae  of  severe  forms  of  asphyxia. 

2.  Atelectasis  Neonatonun 

(Congenital  Collapse  of  the  Lungs) 

Inflation  of  the  lungs  of  the  normal  newborn  begins  with  its  first 
cry  uttered  announcing  its  arrival  into  the  domain  of  the  living.  Suc- 
ceeding respiratory  acts  gradually  unfold  the  originally  collapsed  al- 
veoli and  bronchioles,  and  full  expansion  of  the  lungs  is  ordinarily 


214  DISEASES   OF   CHILDREN 

completed  within  the  first  forty-eight  hours.  The  posterior  portions 
of  the  lower  lobes,  particularly  the  right,  are  last  to  expand. 

Failure  of  the  lungs  fully  to  unfold  gives  rise  to  the  condition  under 
discussion,  i.  e.,  atelectasis  pulmonum. 

Most  alveoli  and  bronchioles  are  collapsed.  The  lung  is  brownish  red 
in  color,  feels  tough  and  resistant  to  the  touch — like  liver — does  not 
crepitate,  and  sinks  in  water.  Usually  both  lungs,  particularly  the  poste- 
rior parts  of  the  lower  lobes,  are  affected.  In  cases  succumbing  to  the 
disease  after  weeks  or  months  there  is  also  found  congestion  of  the 
heart,  spleen  and  liver. 

The  causes  of  atelectasis  are  essentially  the  same  as  those  of  asphyxia ; 
the  former  is  sometimes  a  sequel  of  the  latter,  especially  if  inadequately 
treated.  Inflation  of  the  lungs  is  occasionally  interfered  with  by  congen- 
ital hyperplasia  of  the  thyroid  or  thymus  glands  compressing  the  trachea. 

In  marked  atelectasis  the  infant  makes  but  faint  efforts  to  respire. 
It  is  pale,  sometimes  cyanotic;  its  temperature  is  subnormal  and  its 
pulse  slow  and  weak.  It  is  unable  to  suckle  properly  and  to  cry  aloud. 
It  sleeps  most  of  the  time  and  but  lazily  responds  to  external  influence. 
Auscultation  discloses  weak  and  vesicular  breathing  (never  bronchial) 
and  occasional  crepitation.  Slight  dullness  on  percussion.  The  diagnosis 
may  often  be  verified  by  a  radiogram, 

A  great  number  of  otherwise  healthy  children  recover  under  prompt 
and  energetic  treatment.  Delicate  infants  either  die  a  few  hours,  days 
or  several  weeks  after  birth  from  prostration  following  repeated  at- 
tacks of  cyanosis,  or  survive  and  remain  debile  for  life,  often  suffering 
from  organic  defects,  such  as  incomplete  closure  of  the  foramen  ovale  or 
ductus  arteriosus,  and  the  like. 

The  treatment  of  atelectasis  consists  in  stimulating  the  respiratory 
and  circulatory  functions  by  keeping  the  infant  wide  awake  at  intervals ; 
frequent  change  of  position ;  artificial  respiration ;  alternating  warm  and 
cold  baths  or  showers  followed  by  brisk  friction ;  oxygen  inhalation,  and 
gentle  faradization.  In  all  other  respects  they  should  be  treated  like 
premature  babies. 

3.  Vitia  Cordis 

(See  p.  525) 

4.  Syphilis  Embryonalis  S.  Fetalis 

(See  p.  482) 

5.  Premature  Birth 

Children  born  before  full  term — between  the  twenty-eighth  and 
thirty-eighth  weeks  of  intrauterine  life — are  designated  "premature." 


INJURIES   AND   DISEASES   OF    THE    NEWBORN 


215 


Thanks  to  the  earlier  and  better  recognition  of  syphilis,  the  more 
thorongh  appreciation  of  the  methods  of  its  prevention  and  cure,  as 
well  as  the  tendency  of  the  syphilitic  virus  spontaneously  to  lose  its 
virulence  through  attenuation,  premature  births,  being  due  chiefly  to 
parental  syphilis,  are  no  longer  as  frequent  in  occurrence  as  in  former 
years. 

The  physical  condition  of  premature  infants  rests  largely  upon  the 
period  of  prematurity,  inherent  vigor  of  the  newborn,  and  the  pres- 
ence or  absence  of  serious  organic  defects.  Ordinarily  premature  in- 
fants are  considerably  punier  than  full  term  infants.  They  weigh  and 
measure  approximately — 


WEIGHT 

At  29  weeks    1600  Gm.     3i/i  lb. 


31 
33 
35 
37 
40 


1900  "  4       " 

2100  "  41^  " 

2600  "  514  " 

2800  "  5%  " 

(full  term) 3100  "  614  '' 


40  Cm. 

43  " 

44  " 

47  " 

48  " 
52  " 


SIZE 

15  inches 

I614  inches 

161/^  inches 

17%  inches 

18  inches 

19 1^  inches 


The  body  is  limp ;  the  movements  of  the  extremities  are  helpless  and 
tardy.  The  face  is  usually  sunken  and  senile.  The  skin  is  soft  and 
delicate,  vulnerable  to  an  extreme,  hence  readily  susceptible  to  in- 
fectious processes.  Respiration  is  irregular,  superficial  and  sometimes 
of  the  Cheyne-Stokes  type.  Atelectasis  and  cyanosis  are  not  rare  ac- 
companiments. The  heart  beat  and  pulse  are  weak,  often  irregular, 
and  the  blood  lacks  in  coagulating  power.  The  bones  are  soft,  more 
or  less  yielding  to  light  manipulation.  The  temperature  is  subnormal. 
Premature  infants,  as  a  rule,  are  unable  to  suckle  or  swallow  properly 
and,  owing  to  incapacity  of  the  digestive  organs  and  atony  of  the 
intestinal  musculature,  fully  to  assimilate  the  food  consumed.  Severe 
colic  and  uric  acid  infarcts,  which  latter  often  lead  to  anuria  and  other 
uremic  manifestations,  add  misery  to  their  painful  existence. 

Encumbered  with  so  many  deficiencies,  the  span  of  life  of  the  delicate 
premature  infant  must  obviously  measure  but  a  few  hours  or  days. 
The  mortality  of  premature  infants  under  1,600  grams  in  weight,  es- 
pecially if  they  are  inadequately  cared  for,  is  estimated  to  be  about 
80  per  cent;  of  those  weighing  over  2,000  grams,  40  per  cent;  while 
of  those  weighing  over  2,500  grams  only  20  per  cent — almost  as  low 
as  with  full-term  babies.  Such  as  survive,  however,  often  remain  very  fee- 
ble for  many  years,  manifest  a  greater  tendency  to  disease,  and  lack 
power  of  resistance  to  overcome  it.  Occasionally,  after  many  ups  and 
downs,  premature  infants  marvelously  extricate  themselves  from  the 
pangs  of  death  and  grow  up  full  of  vivacity  and  vigor.     I  have  now 


216 


DISEASES    OF    CHILDREN 


under  observation  a  premature  baby  ten  months  old,  weighing  12  lbs. 
that  at  birth  weighed  only  2i/4  lbs.  For  the  first  six  weeks  it  was  fed 
on  breast  milk  by  means  of  a  catheter  through  the  nose. 

It  is  therefore  incumbent  upon  the  physician  to  look  upon  every 
premature  infant  that  respires  at  birth  as  one  whose  life  can  be  pre- 
served by  suitable  care  and  treatment. 

Management  of  "Feeble  Vitality  of  the  Newborn"  With  Special  Ref- 
erence to  the  Premature  Baby 

Three  special  indications  are  to  be  met  in  the  management  of  the 
newborn,  who  are  delicate.     We  must  (1)   endeavor  to  maintain  the 


Fig.  53. — Incubator  room  for  newly  born  babies  with  feeble  vitality.      (After   Th. 

Escherich.) 

best  features  of  antenatal  life;  (2)  supply  nutriment  suitable  for  the 
infant's  growth  and  development;  and  (3)  awaken  and  strengthen  the 
dormant  or  inefficient  functions  of  its  organs. 

The  first  prerequisite  should  be  met  by  an  artificial  environment 
which  should  as  nearly  as  possible  resemble  that  of  the  interior  of 
the  uterus.  In  very  delicate  and  puny  babies  the  numerous  modern 
incubators  on  the  market,  in  many  instances,  answer  the  purpose. 

The  temperature  of  the  incubator  is  maintained  steadily  at  about 
96°  F.,  and  fresh  air  supplied  by  the  automatic  ventilating  contrivance 
and  by,  off  and  on,  leaving  the  door  open.  Infants  showing  a  fair 
amount  of  vitality  usually  get  along  very  well  without  incubators, 


INJURIES   AND   DISEASES    OF    THE    NEWBORN 


217 


the  latter  being  supplanted  by  ordinary  bassenets  and  warm-water 
bags,  or  preferably  the  modern  electric  pads.  The  infant  is  clothed 
ill  a  woolen  shirt  and  napkin  and  placed  in  the  incubator  or  is  Avrapped 
in  a  ''premature  gown"  which  consists  of  a  layer  of  absorbent  cotton 
between  two  layers  of  gauze.  A  hood  of  the  same  material  is  attached 
to  the  body  of  the  gown.  The  temperature  of  the  baby's  room  should 
range  between  74  to  78°  F.,  or  higher  if  the  baby's  temperature  con- 
tinues subnormal. 

Delicate  incubator  babies  should  be  disturbed  as  little  as  possible, 
and  removed  only  for  feeding  and  cleansing  (by  means  of  lukewarm 
oil)  or  for  such  therapeutic  purposes  {e.g.,  artificial  respiration,  as  ne- 
cessity arises).  Bathing  is  contraindicated,  and  any  undue  handling 
of  the  skin  or  mucous  membranes  must  be  carefully  avoided,  since  most 
trifling  injuries  are  very  apt  to  be  followed  by  fatal  sepsis. 

Every  effort  should  be  made  to  feed  the  premature  infant  on  woman's 
milk  for  at  least  the  first  few  weeks  of  extrauterine  life.  When  too 
weak  to  suckle  from  the  breast,  the  milk  may  be  given  every  three 


Fig.  54. — -Breck's  feeder 


hours  by  means  of  a  dropper  or  Breck's  feeder,  care  being  taken  that 
the  milk  flows  down  into  the  throat  very  slowly,  lest  it  enter  the  trachea 
and  lead  to  aspiration  pneumonia.  In  the  absence  of  breast  milk, 
light  mixtures  of  cow's  milk  (%  per  cent  of  fat,  %  per  cent  protein, 
and  6  per  cent  of  milk  sugar)  should  be  administered  every  two  to 
three  hours  in  quantities  of  4  to  8  teaspoonfuls.  The  amount  is  grad- 
ually to  be  increased.  If  the  baby  is  unable  to  swallow,  the  milk  may 
be  administered  by  gavage,  or  by  catheter  through  the  nose. 

The  third  indication  applies  principally  to  infants  who,  though  born 
at  full  term,  possess  very  little  vitality,  and  whose  organs,  especially 
the  heart  and  lungs,  fail  to  functionate.  The  vitality  is  best  aroused 
by  artificial  respiration — by  alternate  flexion  and  extension  of  the 
infant's  body  while  it  lies  upon  the  operator's  palms.  An  occasional 
dash  of  cold  water  upon  its  face,  to  induce  the  child  to  cry  aloud  and 
to  take  deep  breaths,  and  stimulation  by  means  of  oxygen,  caffeine 
and  digitalis  serve  as  useful  adjuvants. 


218  DISEASES    OF    CHILDREN 

Sclerema  Neonatorum 

(Sclerema  Adiposum) 

This  very  rare  affection  may  be  primary,  without  any  apparent 
cause,  or  secondary  in  nature  as  a  result  of  great  loss  of  body  fluids 
(internal  hemorrhages,  gastrointestinal  disease)  or  extensive  exuda- 
tions into  interna:!  cavities  (thorax).  It  occurs  principally  in  the  pre- 
mature, very  feeble  and  badly  nourished  infants  in  the  first  few  days 
of  life,  but  also  very  much  later,  up  to  six  months  of  age. 

It  begins  in  the  lower  extremities,  particularly  the  calves.  From 
here  it  spreads  symmetrically  over  the  thighs,  loins,  trunk,  neck,  upper 
extremities  and  head,  leaving  penis,  scrotum,  planta  pedis,  and  palma 
manus  uninvolved.  The  skin  is  dirty  yellow,  very  tense,  cold,  hard, 
immovable  over  the  underlying  structures,  and  does  not  pit  on  pres- 
sure. 

From  day  to  day  the  skin  becomes  more  indurated,  marbleized, 
and  the  patient  lies  stiff  with  rigid,  mask-like  face  and  firmly  closed 
mouth  as  though  in  a  state  of  tetanus.  Sucking  is  often  impossible. 
There  is  gradual  sinking  of  all  vital  functions.  The  temperature  falls 
(to  85°  F.,  or  lower),  the  heart  action  becomes  weak,  the  pulse  is 
slow  and  barely  perceptible,  respiration  shallow  and  irregular,  the 
voice  feeble  and  whining,  the  intestines  and  kidneys  are  inactive,  the 
child  wastes  rapidly  and  death  ensues  in  about  a  week  from  exhaustion 
or  from  some  complication,  the  commonest  being  pneumonia  and  sepsis. 
Milder  cases,  especially  older  infants,  not  infrequently  recover. 

Treatment. — Early  hypodermo-  and  entero-clysis  with  hot  (104°  to 
106°  F.),  normal  saline  solution  (from  2  to  3  ounces  t.  i.  d.)  ;  gentle 
massage  with  oil ;  stimulation ;  maintenance  of  body  heat ;  careful  feed- 
ing, etc.,  as  outlined  under  ''Feeble  Vitality  of  the  Newborn,"  (See  p. 
216.) 

Scleredema  Neonatorum 

(Sclerema  Serosum) 

This  form  of  ed^ma  affects  especially  premature,  weak  (twins),  ate- 
lectatic and  syphilitic  infants.  It  usually  begins  a  few  days  postpartum 
(it  is  rarely  congenital)  with  puffiness  and  swelling  of  the  feet  and  legs. 
The  edema  soon  extends  upward  (involving  also  the  mons  veneris, 
scrotum  and  penis)  over  the  entire  body  except  the  chest,  and  rarely 
the  eyelids  and  face.  The  skin  is  tense,  shiny,  waxy  white,  or  cyanotic, 
and  pits  on  pressure.  When  the  edema  increases  it  greatly  resembles 
true  sclerema,  but  may  be  differentiated  from  the  latter  by  bearing 
in  mind  the  following  characteristic  symptoms: 


INJURIES    AND   DISEASES    OF    THE    NEWBORN  219 

SCLEREMA  SCLEREDEMA 

Color  of  skin   Dirty  yellow.  Shiny   or   mottled. 

Parts  exempt Genitals,    palms    of    the  Chest. 

hands  and  soles  of  the 

feet. 
Pitting  on  pressure Absent.  Marked. 

The  general  symptoms,  such  as  low  temperature,  great  depression, 
etc.,  are  not  quite  as  pronounced  as  in  sclerema  adiposum. 

The  prognosis  is  not  as  grave  as  in  true  sclerema. 

The  treatment  consists  chiefly  of  stimulation  (camphor,  digitalis) 
hot  baths,  massage  and  passive  motion,  active  diuresis  and  proper 
feeding.     (See  also  "Feeble  Vitality  of  the  Newborn,"  p.  216.) 

Sepsis  Neonatorum 

AVith  the  usual  aseptic  precautions  that  are  now  being  taken  in  the 
management  of  labor  and  the  puerperium,  the  number  of  cases  of  sep- 
sis neonatorum  has  been  reduced  to  a  minimum.  This  is  true  espe- 
cially of  systemic  sepsis.  The  extreme  importance,  however,  of  the 
subject  in  question,  demands  its  careful  consideration. 

LOCAL  SEPSIS 

Omphalitis  (Inflammation  of  the  Navel) 

Simple  omphalitis  is  manifested  by  delayed  closure  of  the  umbilical 
wound  after  separation  of  the  umbilical  cord,  wetness,  slight  suppura- 
tion, and  incrustation.  There  is  no  inflammatory  reaction  in  the  sur- 
rounding parts.     The  general  health  is  undisturbed. 

Phlegmonous  omphalitis  usually  begins  the  second  week  after  birth. 
The  navel  forms  an  ulcerated  conical  projection.  The  surrounding  tis- 
sue is  firm,  infiltrated,  glossy  and  painful  to  the  touch.  Sometimes  the 
inflammation  extends  rapidlyi  over  the  abdominal  wall  or  into  the 
deeper  structures,  giving  rise  to  peritonitis.  In  one  case  under  obser- 
vation, secondary  suppurative  foci  developed  in  the  lower  portion  of 
the  gladiolus  sterni  (leaving  behind  an  open  fistula)  and  in  the  left 
hip-joint,  completely  destroying  the  caput  femoris  and  giving  rise  to 
a  permanent  dislocation  (Fig.  55).  The  constitutional  symptoms  vary 
with  the  degree  of  the  severity  of  the  affection,  but  are  sufficiently 
pronounced  to  make  the  child  quite  ill  and  to  render  the  prognosis 
doubtful.  Milder  cases  may  terminate  in  suppuration,  but  with  careful 
treatment  (see  p.  221)  end  in  recovery. 


220 


DISEASES   OF    CHILDREN 


Fig.  55. — Absorption  of  left  head  of  femur  and  consequent  dislocation  of  the 
hip  in  a  child  two  years  old  as  a  direct  result  of  sepsis  neonatorum  which  began  with 
an  infection  in  the  navel. 


INJURIES   AND   DISEASES    OF    THE    NEWBORN  221 

Erysipelatoid  omphalitis  is  a  verj-  grave  affection,  often  terminating 
fatally  either  within  a  few  days  from  exhaustion  or  a  week  to  ten  days 
later  from  septic  peritonitis,  icterus,  and  local  suppuration.  The  symp- 
toms and  treatment  are  the  same  as  in  ordinary'  erysipelas. 

Diphtheritic  omphalitis  (ulcus  umbilici)  is  characterized  by  a  fibri- 
nous umbilical  exudation  which,  when  cast  off,  leaves  behind  a  super- 
ficial or  deep  ulcer.    Occasionally  it  is  due  to  the  Klebs-Loflfler  bacillus. 

Gangrenous  omphalitis  ends  fatally  in  the  majority  of  cases.  At  first 
a  small,  discolored,  ulcerated  spot,  if  not  immediately  arrested,  it 
rapidly  develops  into  a  large,  gangrenous,  fetid  mass.  It  sometimes 
extends  into  the  deeper  structures,  giving  rise  to  peritonitis,  urinary 
and  fecal  fistulse,  profuse  hemorrhage  and  pronounced  constitutional 
symptoms. 

Treatment. — As  the  umbilical  wound  forms  the  principal  and  most 
frequent  portal  of  entry  for  septic  infection,  the  importance  of  caring 
for  the  umbilicus  with  the  minutest  detail  is  quite  obvious.  Strictest 
cleanliness  should  be  enforced  and  unnecessary  handling  prohibited. 
Clean  scissors,  clean  ligature,  preferably  composed  of  several  strands  of 
cotton  or  silk  thread,  and,  above  all,  clean  hands  should  be  used  in  cut- 
ting, ligating  and  dressing  the  cord.  The  dressing  should  consist  of  a 
few  layers  of  sterile  linen  cloths  and  dusting  powder  ( 1  part  of  salicylic 
acid  and  6  parts  of  starch)  and  be  changed  every  alternate  day,  preceded 
by  cleansing  the  wound  with  a  little  pure  alcohol  to  hasten  desiccation 
of  the  umbilical  rest.  As  moisture  favors  the  growth  and  absorption 
of  the  bacteria  which  accumulate  at  the  naval  wound,  the  child  should 
receive  daily  a  sponge  bath  instead  of  a  tub  bath,  until  the  navel  has 
completely  cicatrized. 

To  prevent  hernia  as  well  as  access  of  dirt,  the  umbilical  band  should 
be  continued  for  a  few  weeks  after  complete  healing  of  the  navel. 

If  inflammation  of  the  navel,  no  matter  how  slight  in  degree,  occurs 
notwithstanding  all  the  precautions,  it  should  receive  immediate  and 
energetic  treatment.    Procrastination  is  dangerous,  nay,  often  fatal. 

Cauterization  of  the  affected  parts  with  a  2  per  cent  to  5  per  cent  so- 
lution of  nitrate  of  silver,  once  a  day  or  less  often,  is  very  useful  in 
all  forms  of  omphalitis.  The  wound  should  be  kept  scrupulously  clean, 
and  protected  by  a  moist  (boric  acid,  4  per  cent  solution)  gauze  dress- 
ing, covered  by  rubber  tissue.  If  the  septic  process  does  not  yield 
to  this  treatment  early,  a  surgeon  should  be  consulted.  A  bacterio- 
logic  examination  may  prove  helpful  in  giving  a  correct  clue  as  to 
the  treatment,  as  for  example,  in  diphtheritic  omphalitis,  where  diph- 
theria antitoxin  is  of  undoubted  benefit.  (See  ''Biologic  Therapeu- 
tics," pp.  75  and  82.) 


222  DISEASES   OF    CHILDREN 

Omphalorrhagia   (Bleeding  from  the   Navel — Idiopathic   Umbilical 

Hemorrhage) 

Umbilical  hemorrhage  may  occur  as  a  result  of  tearing  the  cord  dur- 
ing delivery,  defective  ligation,  or  imperfect  establishment  of  respira- 
tion (delaying  the  closure  of  the  umbilical  vessels).  The  hemorrhage 
may  be  slight  or  severe,  but  is  readily  controllable.  In  contradistinc- 
tion to  these  forms  of  navel  bleeding  which  take  place  soon  after  birth, 
there  is  another  variety  of  bleeding  from  the  navel,  the  so-called 
idiopathic  or  spontaneous  umbilical  liemorrliage  which  occurs  at  about 
the  time  the  umbilical  rest  separates  (between  the  fourth  and  ninth 
days).  The  bleeding  takes  the  form  of  a  steady  oozing  of  blood  as 
though  coming  from  a  compressed  wet  sponge.  It  is  probably  due  to 
sepsis  of  the  umbilical  blood  vessels.  Some  authors  are  inclined  to  at- 
tribute it  to  congenital  syphilis  or  transitory  hemophilia.  (See  p.  229.) 
In  a  great  many  instances  the  hemorrhage  cannot  be  arrested,  death 
taking  place  either  from  exsanguination  or  from  gradual  exhaustion 
and  complications  (sepsis). 

For  details  of  treatment  see  ''Helena." 

Umbilical  Granuloma  (Excrescence,  Fungus,  Sarcomphalos) 

It  is  a  strawberry-like,  small  tumor,  attached  to  a  broad  base  or 
pedicle  at  the  umbilical  stump.  It  bleeds  readily  and  usually  dis- 
charges thin  pus.  Like  exuberant  granulations  in  other  localities,  it  is 
promptly  cured  by  a  few  applications  of  nitrate  of  silver  (the  stick, 
or  10  per  cent  solution).  It  should  not  be  confounded  with  "Per- 
sistent Omphalomesentericus." 

Ophthalmoblennorrhea  Neonatorum  (Gonorrheal  or  Purulent 

Ophthalmia) 

Gonorrheal  ophthalmia  is  caused  by  infection  of  the  conjunctiva 
of  one  or  both  eyes  by  the  Neisser  gonococcus.  The  inoculation  usu- 
ally occurs  during  the  passage  of  the  head  through  the  parturient  canal 
containing  a  gonorrheal  discharge.  It  may  also  be  conveyed  to  the 
eyes  of  the  infant  postpartum  by  means  of  the  fingers  of  the  attendant 
or  articles  in  use  which  have  been  soiled  by  the  purulent  discharge. 

The  disease  begins  two  or  three  days  after  the  gonorrheal  inocula- 
tion, with  intense  tumefaction  of  the  lids,  redness,  swelling  and  thick- 
ening of  the  conjunctivae,  lacrimation,  and  mucous  and  mucopurulent 
secretion.  From  day  to  day  the  discharge  becomes  thicker  and  more 
purulent;  the  conjunctiva  assumes  a  velvet-like  appearance  (chemo- 


INJURIES   AND   DISEASES   OF    THE    NEWBORN 


223 


sis),  and  papillary  deposits  or  longitudinal  folds  appear  upon  the  con- 
junctiva bulbi.  If  not  immediately  arrested,  especially  if  the  purulent 
secretion  is  allowed  to  accumulate  between  the  edematous,  pasted 
lids,  the  disease  spreads  rapidly  to  the  cornea  causing  haziness,  mac- 
eration and  partial  or  total  perforation.  As  a  result  of  the  latter 
and  depending  upon  its  location,  total  or  partial  staphyloma,  panoph- 
thalmitis, with  phthisis  bulbi,  capsular  cataract,  and  anterior  synechia} 
may  supervene. 

Occasional^,  particularly  in  delicate  infants,  gonorrheal  conjunc- 
tivitis gives  rise  to  numerous  complications,  such  as  articular  affec- 
tions, gonorrheal  rhinitis,  stomatitis,  etc. 

The  duration  of  the  disease  varies  from  four  to  eight  weeks. 

Until  the  introduction  of  Crede's  method  of  prophylaxis,  gonorrheal 
ophthalmia  was  supposed  to  have  contributed  60  per  cent  of  the  cases 
of  blindness  of  one  or  both  eyes.  At  present  the  percentage  has  been 
reduced  to  one-third,  and  with  early  and  careful  treatment  the  prog- 
nosis is  still  more  favorable. 


Proportion  of  Pupils  Newly  Admitted  to  New  York  Schools  for  the  Blind 

During  the  Past  Ten  Years  "Who  Are  Blind  From 

Ophthalmia  Neonatorum 


School 

No.  of 

Total  new 

Blind 

Per  cent 

Year 

public   schools 

admissions 

from  0.  N. 

1907-08 

10 
14 

290 
300 

77 
68 

26.5 

1908-09 

22.6 

1909-10 

13 
15 

24 

32'5 
351 
415 

67 
84 
88 

20.6 

1910-11 

23.9 

1911-12 

21.2 

1912-13 

21 
19 

386 
428 

88 
84 

22.7 

1913-14 

19.6 

1914-15 

28 

602 

91 

15.1 

1915-16 

35 

666 

12'7 

19.0 

1916-17 

34 

647 

119 

18.4 

Gonorrheal  ophthalmia  is  not  to  be  confounded  with  simple  con- 
junctivitis not  infrequently  met  in  the  newborn  in  connection  with  local 
sepsis.  The  latter  variety  is  readily  recognized  by  the  absence  of  gon- 
ococei  in  the  discharge  and  by  its  much  milder  course. 

Treatment. — ^Where  there  is  the  least  suspicion  of  gonorrhea  in  the 
mother,  her  parturient  canal  and  external  genitalia  should  be  carefully 
disinfected  by  a  bichlorid  solution  (1  to  5000)  before,  during,  and  after 
delivery.  In  addition  to  this,  the  following  directions  in  the  way  of 
prophylaxis  (Crede's  method)  should  be  promptly  resorted  to:  Wash 
off  each  eye  with  a  boric  acid  wipe ;  into  each  eye  instill  two  drops  of  a  2 


224  DISEASES   OF   CHILDREN 

per  cent  solution  of  silver  nitrate ;  in  about  thirty  seconds  wasli  out  the 
excess  with  saline  solution.  This  should  be  done  as  early  after  birth  as 
possible.  During  the  puerperal  state  tlie  child  should  be  kept  away 
from  the  mother. 

If  only  one  eye  be  affected  the  fellow  eye  should  be  securely  covered 
by  a  watch-glass  or  a  small  pad  of  lint,  oiled  silk  and  roller  bandage. 
This  protected  eye  should  be  inspected  and  cleansed  twice  daily. 

As  soon  as  the  child  is  seen  by  the  physician,  he  should  pencil  the 
affected  eye  with  a  2  per  cent  silver  solution.  If  this  occurs  early,  the 
ophthalmia  may  sometimes  be  arrested  in  its  incipiency  or  at  least 
rendered  milder  in  its  course. 

The  affected  eye  must  be  handled  by  the  nurse  from  behind  the  pa- 
tient's head.  Small,  round  layers  of  lint  are  transferred,  every  three 
to  five  minutes  from  a  large  square  of  ice  to  the  affected  eye,  con- 
tinuously for  one  hour.  An  intermission  of  one  hour  is  then  given 
and  the  cold  applications  are  resumed.  This  should  be  continued  day 
and  night  until  there  is  positive  evidence  of  abatement  of  the  inflam- 
mation and  excretion.  This  usually  occurs  within  two  weeks.  The 
eyes  should  be  carefully  but  very  gently  cleansed  every  half  hour  with 
warm,  saturated  solution  of  boric  acid  (4  per  cent).  If  the  lids  are  so 
swollen  as  not  to  permit  thorough  cleansing,  canthotomy  may  have  to 
be  resorted  to.  Silver  being  the  most  proficient  antigonocoecus,  a 
2  to  3'  per  cent  solution  should  be  applied  to  the  conjunctiva  daily  so 
long  as  the  excretion  is  profuse  and  less  often  when  it  becomes  more 
scanty  and  less  purulent.  Instead  of  nitrate  of  silver  we  may  employ 
argyrol,  silvol,  solargentum,  or  protargol  in  from  5  per  cent  to  10  per 
cent  solutions.  In  involvement  of  the  cornea  the  ice  cloths  should  be 
discontinued,  and  warm  applications  used  instead.  A  1  per  cent 
solution  of  atropine  should  be  used  as  necessity  arises.  In  bad  cases 
antigonocoecus  vaccine  is  worth  trying. 

Examination  of  the  discharge  for  gonococci  should  be  made  at  least 
once  a  week,  and  the  case  should  not  be  regarded  noncontagious  and 
out  of  danger  until  the  discharge  from  the  eye  remains  free  from 
gonococci  for  at  least  two  weeks.  The  treatment  of  gonorrheal  oph- 
thalmia should  not  be  intrusted  to  unskillful  hands.  The  better  trained 
the  nurse  is  in  handling  serious  eye  cases,  the  more  rapid  and  perfect 
the  recovery. 

Pemphigus  Neonatorum 

Simple,  nonsyphilitic  pemphigus  (see  p.  484)  makes  its  appearance 
between  the  fifth  and  twentieth  day  of  the  child's  life.  It  is  quite 
communicable,  sometimes  epidemic,  and  is  probably  due  to  the  staphy- 


INJURIES   AND   DISEASES   OF    THE   NEWBORN  225 

lococcus  pyogenes  aureus.  Its  seat  of  predilection  is  the  abdomen  and 
inguinal  region,  but  the  lesion  may  be  found  on  any  part  of  the  body. 
It  but  very  rarely  affects  the  palms  of  the  hands  and  the  soles  of 
the  feet,  herein  markedly  differing  from  syphilitic  pemphigus.  The 
eruption  consists  of  tense  bull®,  varying  in  size  from  a  lentil  to  a 
quarter  of  a  dollar  piece  and  contains  a  serous,  rarely  seropurulent  fluid. 
The  blebs  are  situated  upon  a  reddened  base,  and  on  bursting  leave 
moist,  red  spots  which  very  soon  are  covered  over  by  skin.  Occa- 
sionally ulceration  of  the  skin  supervenes,  and  is  accompanied  by  high 
fever  and  other  constitutional  symptoms  (malignant  pemphigus). 
This  severe  form  of  the  disease  is  observed  particularly  in  cachectic 
and  bottle-fed  infants  exposed  to  insanitary  surroundings,  and  often 
leads  to  a  fatal  issue.  In  otherwise  healthy,  well-nourished  and  well- 
kept  infants,  recovery  may  be  expected  within  from  two  to  three 
weeks. 

Simple  pemphigus  is  preventable  by  strict  attention  to  general  hy- 
giene and  proper  feeding.  Those  in  charge  of  the  child  should  be 
cautioned  as  to  the  communicability  of  the  disease.  If  large  surfaces 
are  involved,  warm  baths  are  very  useful,  preferably  with  boric  acid  (2 
per  cent),  solutions.  They  may  be  administered  two  or  three  times  a 
day  and  followed  by  dusting  over  the  moist  surface  with — 

I^     Bismuthi  subgall., 

Acidi  salieyl   aa  gr.  x.     i      0.6 

Zinci  stearat Si     |    30.0 

and  enveloping  the  body  in  cotton.  Occasionally,  applications  of  a 
2  per  cent  solution  of  nitrate  of  silver.  Autogenous  vaccine  in  malig- 
nant cases. 

Dermatitis  Exfoliativa  Neonatorum 

Slight  dermatitis,  or  erythema,  with  or  without  desquamation,  is 
more  or  less  physiologic  in  the  newborn.  There  is,  however,  an  ob- 
scure (sepsis?)  form  of  exfoliative  dermatitis  which  is  peculiar  to  early 
infancy  (usually  in  the  second,  rarely  after  the  fifth  week  of  life), 
and  is  closely  related  to  pemphigus.  It  begins  with  inflammation  of 
the  oral  mucous  membrane,  rhagades  at  the  angles  of  the  mouth,  and  dif- 
fuse redness  of  the  entire  body,  followed  by  active  desquamation  of  the 
skin  in  large  lamellae.  It  is  sometimes  preceded  by  detachment  of 
skin  and  bursting  of  vesicles  filled  with  clear  fluid.  Not  infrequently 
the  erosions  extend  to  the  oral  mucous  membrane. 

The  disease  runs  its  (afebrile)  course  in  a  few  weeks,  and  in  robust 
children  ends  favorably.    In  delicate  children  it  may  be  followed  by 


22G  DISEASES    OF    CIllLDRlON 

general  furunculosis  or  even  gangrene,  gastrointestinal  disturbances 
and  pneumonia,  and  prove  fatal. 

Like  nonsyphilitic  pemphigus,  dermatitis  exfoliativa  is  preventable  by 
scrupulous  cleanliness,  and  the  avoidance  of  local  irritation.  The 
local  treatment  consists  of  inunctions  of  1  per  cent  salicylic  or  carbolic 
acid  oil. 

GENERAL  SEPSIS 

In  speaking  of  primarily  local  septic  affections,  attention  has  been 
directed  to  the  frequency  with  which  grave  constitutional  symptoms 
are  observed  during  their  protracted  course.  In  these  eases  the  sys- 
temic manifestations  are  secondary  to  the  local  ones,  and  if  the  latter 
are  detected  and  treated  early,  the  former  may  be  prevented  or  ar- 
rested in  their  incipiency.  We  are  now  about  to  describe  a  group  of 
diseases  in  the  newborn,  which  either  present  no  visible  local  lesions 
at  all,  or  are  so  slight  as  to  escape  attention  in  their  early  stages. 

Tetanus  (Trismus)  Neonatorum 

Tetanus  in  the  newborn,  like  the  corresponding  disease  in  the  adult, 
is  due  to  the  tetanus  bacillus  (Nicolaier,  Kitasato).  Infection  usu- 
ally occurs  through  the  umbilical  stump  or  circumcision  wound.  The 
bacillus  multiplies  by  spore  formation  and  generates  toxins  which  en- 
ter the  system  and  are  absorbed  principally  by  the  ending  of  the 
motor  nerves.  From  here  the  toxins  are  ultimately  carried  to  the 
anterior  horns  of  the  spinal  cord  and  the  nuclei  of  the  medulla  oblon- 
gata— hence  the  tetanic  contractions. 

The  symptoms  begin  within  the  first  week  after  birth,  or  later 
after  ritual  circumcision,  with  restlessness,  dropping  of  the  nipple 
of  the  breast  or  bottle  with  a  cry,  and  tension  of  the  masseters.  The 
spasm  rapidly  involves  the  orbicularis  oris  and  palpebrarum  muscles, 
the  lower  jaw^  becomes  rigid,  the  mouth  proboscidiform,  the  forehead 
and  cheeks  are  wrinkled,  and  the  eyelids  are  half  closed  (risus  sardoni- 
cus).  The  hands  are  clenched,  the  legs  flexed  and  abducted  and,  vary- 
ing with  the  degree  of  severity  of  the  attack,  there  is  more  or  less 
marked  opisthotonos.  At  first  the  paroxysms  occur  only  during  the 
act  of  nursing,  gradually,  however,  more  frequently  and  more  per- 
sistently. In  severe  cases  there  are  also  spasms  of  the  glottis,  of  the 
esophagus,  and  diaphragm,  and  in  consequence  attacks  of  asphyxia 
which  may  end  fatally.  On  the  other  hand,  the  affection  may  run 
a  protracted  course,  sometimes  for  weeks,  and  occasionally  end  in  re- 
covery. 


INJURIES   AND   DISEASES   OF    THE   NEWBORN 


227 


The  more  violent  the  attacks  and  the  higher  the  temperature,  the 
less  favorable  the  prognosis.  Seventy  per  cent  of  the  cases  succumb 
within  a  few  days,  either  from  spasm  of  the  diaphragm  or,  more  rarely, 
from  exhaustion. 

Treatment. — Careful  protection  against  wound  infection  and  prompt 
attention  to  existing  traumatism.  Considering  the  very  grave  prog- 
nosis under  the  ordinary  methods  of  treatment  and  the  occasional 
success  obtained  by  means  of  hypodermic  or  subdural  administration 
of  tetanus  antitoxin,  the  latter  should  be  resorted  to  at  the  earliest 
possible  time,  either  as  a  prophylactic  immediately  after  the  injury 


Fig.  56. — High  degree  of  "tetanism"  greatly  resembling  tetanus  neonatorum. 
Fig.  59,  showing  same  case  during  partial  relaxation  of  the  spasm. 


Note 


(500  units)  or  as  a  curative  measure  (2,000  units  p.  r.  n.),  in  addition 
to  the  symptomatic  treatment  generally  in  vogue. 

The  Department  of  Health  of  the  City  of  New  York  suggests  the 
following  procedures  in  a  developed  case : 

A  lumbar  puncture  having  been  performed  in  the  usual  way,  1000 
to  2000  units  of  antitoxin,  heated  to  body  temperature,  are  allowed  to 
run  into  the  spinal  canal  by  gravity.  In  order  that  the  antitoxin  may 
be  distributed  throughout  the  length  of  the  cord,  it  should,  if  necessary, 


228  DISEASES   OP    CHILDREN 

be  diluted  with  sterile  saline  to  a  volume  of  at  least  5  c.c.  In  ease 
of  a  "dry  tap,"  which  has  been  reported  on  good  authority  as  occa- 
sionally occurring  in  this  disease,  this  amount  should  not  be  exceeded, 
but  when  an  abundance  of  spinal  fluid  is  obtained,  the  intraspinal  dose 
should  be  little  less  than  that  of  the  fluid  withdrawn.  An  intravenous 
injection  of  3000  units  should  be  given  at  the  same  time  in  order  to 
render  the  blood  highly  antitoxic  at  once.  The  intraspinal  injection 
may  be  repeated  in  24  hours  and  again  in  48  hours,  but  a  third  dose  is 
probably  unnecessary.  A  subcutaneous  injection  of  2000  units  may 
also  be  given  on  the  fourth  day  to  sustain  the  antitoxic  strength  of 
the  blood.  If  for  any  reason  the  attending  physician  is  not  able  to 
give  an  intraspinal  injection,  an  intravenous  dose  of  3,000  to  5,000 
units  should  be  given.  If  this,  too,  is  impossible,  rather  than  delay, 
the  same  dose  or  a  larger  one  should  be  given  intramuscularly,  sev- 
eral muscles  being  used,  and  arrangements  immediately  made  to  give 
an  intraspinal  and  intravenous  dose  at  the  earliest  possible  moment. 
The  use  of  antitoxin  does  not  do  away  with  the  necessity  for  thorough 
surgical  treatment  of  the  wound  if  it  has  not  already  healed.  The  pa- 
tient should  be  protected  as  carefully  as  possible  from  noise,  excessive 
light,  drafts,  jars,  and  other  forms  of  irritation.  Any  irritation  of  the 
skin  should  be  avoided.  To  combat  individual  symptoms  we  may  resort 
to  lukewarm  baths,  choral  hydrate,  the  bromides  per  rectum,  and  heart 
stimulants,  especially  camphor.  Feeding  (mother's  or  diluted  cow's 
milk)  with  a  soft  rubber  tube  through  the  nose. 

Arteritis  and  Phlebitis  Umbilicalis 

This  condition  is  usually  observed  secondarily  to  omphalitis  (g. -y.), 
but  may  occur  as  a  primary  disease.  In  the  latter  event  no  local  alter- 
ations are  discernible  at  the  navel,  and  the  grave  affection  frequently 
escapes  notice  until  pronounced  symptoms  of  general  sepsis  make  their 
appearance.  These  consist  of  restlessness,  fever,  prostration  and  death 
within  a  few  days,  or  gradual  exhaustion  from  numerous  complica- 
tions. In  umbilical  phlebitis  intense  icterus — from  extension  of  the 
inflammation  to  the  liver — forms  a  characteristic  symptom.  In  some 
cases  of  arteritis  and  phlebitis  umbilicalis  a  fistulous  tract  is  observed 
at  the  navel  which  on  pressure  discharges  blood  and  pus  containing 
pathogenic  microorganisms. 

For  prophylactic  and  local  treatment  see  '  *  Omphalitis  "  (p.  221 ) .  The 
constitutional  symptoms  call  for  symptomatic  treatment.  Thus,  care- 
ful feeding,  preferably  breast  milk;  active  stimulation  by  means  of 
enteroclysis,  hypodermoclysis,  sterile  camphorated  oil,  etc.  Antistrep- 
tococcic serum  is  deserving  of  trial. 


INJURIES   AND   DISEASES   OF    THE    NEWBORN  229 

Erysipelas  Neonatorum 

This  affection  begins  suddenly,  with  high  fever,  convulsions,  and 
often  other  symptoms  of  general  sepsis.  The  glossy  redness  rapidly 
extends  over  large  areas,  often  over  the  entire  body.  The  disease 
proves  fatal  in  a  few  days,  and  the  cases  that  survive  the  acute  attack 
usually  succumb  to  cutaneous  necrosis  (particularly  of  the  scrotum, 
extremities),  copious  diarrhea,  septic  peritonitis,  pneumonia,  and  ex- 
haustion. 

The  treatment  is  principally  prophylactic.  The  inflamed  areas 
should  once  a  day  be  painted  with  pure  ichthyol,  or  kept  moist  with 
gauze  saturated  with  a  50  per  cent  solution  of  Epsom  salts.  In  one 
desperate  case  under  our  care  the  rapid  spread  of  the  inflammation 
was  arrested  by  painting  the  afl'ected  parts  with  pure  carbolic  acid 
followed  by  sponging  with  absolute  alcohol.     Antistreptococcus  serum. 

Melena  Neonatorum 

Melena  vera  should  not  be  mistaken  for  melena  spuria,  in  which  con- 
dition the  blood  originates  from  erosions  in  the  mouth  or  nasopharynx 
or  from  swallowing  of  blood  from  fissured  nipples,  etc. 

Melena  vera  usually  begins  in  the  first  few  days  of  the  child's  life 
with  bleeding  from  the  bowels,  and  often  with  hematemesis.  As  a 
rule,  the  blood  is  mixed  with  stool,  and  is  dark  brown  or  black  in 
color.  In  some  cases  the  loss  of  blood  is  slight,  recurs  at  long  in- 
tervals and  terminates  spontaneously  without  serious  consequences 
except  tedious  convalescence.  In  the  majority  of  cases  of  genuine 
melena,  however,  the  bloody  discharge  is  profuse  and  leads  to  rapidly 
increasing  anemia  and  collapse.  Eliminating  the  group  of  cases  which 
are  due  to  a  hemophilic  dyscrasia,  authorities  are  not  agreed  on  the 
actual  cause  of  true  melena.  In  a  number  of  eases  postmortem  exam- 
ination disclosed  erosions  and  ulcerations  of  the  stomach  and  intes- 
tines which  are  attributed  to  thrombosis  of  the  umbilical  vein  or  the 
ductus  Botalli.  The  consensus  of  opinion,  however,  favors  the  septic 
origin  of  the  necrosis  erosions.      (For  treatment  see  p.  230.) 

Epidemic  Hemoglobinuria  With  Icterus  in  the  Newborn 

(Cyanosis  Icterica  Cum  Hemoglobinuria,  Winckel's  Disease) 

This  extremely  grave  (90  per  cent  mortality)  epidemic  affection 
makes  its  appearance  about  the  fourth  day  postpartum,  in  apparently 
healthy-born  and  well-developed  children.  The  infant  becomes  rest- 
less, refuses  nourishment,  shows  signs  of  respiratory  disturbance  and 
slight  rise  of  temperature.     The  skin  turns  greenish  yellow,  and  soon 


230  DISEASES    OF    CHILDREN 

deeply  jaundiced  and  cyanotic.  Collapse,  somnolence  and  convulsions, 
rarely  preceded  also  by  vomiting  and  diarrhea  (no  blood),  are  rapidly 
followed  by  death.  The  urine  is  pale  brown,  contains  hemoglobin, 
renal  epithelium,  granular  and  blood  casts,  and  masses  of  detritus, 
but  no  free  blood  corpuscles. 

The  autopsy  reveals  congestion  and  fatty  degeneration  of  the  inter- 
nal organs,  with  punctiform  hemorrhages,  especially  in  the  mucous  and 
serous  membranes;  masses  of  granular  hemoglobin  in  the  kidneys  and 
spleen  and  thickening  of  the  blood. 

Acute  Fatty  Degeneration  of  the  Newborn  (Buhl's  Disease) 

The  essential  anatomic  features  of  this  rare  but  very  malignant  af- 
fection are  fatty  degeneration  of  the  internal  organs,  notably  the  heart, 
liver  and  kidneys,  and  hemorrhages  in  the  viscera,  and  into  the  serous 
cavities. 

The  disease  attacks  full-term  infants  who  for  some  inexplicable  rea- 
son are  born  asphyxiated.  Those  few  who  survive,  respire  badly,  are 
cyanotic,  or  rather  icteric,  and  present  hemorrhages  in  the  skin  and 
mucous  membranes,  from  the  alimentary  canal,  and  the  umbilicus. 
They  almost  invariably  succumb  before  the  end  of  the  second  week 
from  progressive  anemia,   anasarca,  and  collapse. 

Treatment. — The  indications  for  the  treatment  of  any  of  the  afore 
mentioned  hemorrhagic  manifestations  are:  (1)  to  arrest  the  hemor- 
rhage ;  (2)  to  improve  or  at  least,  maintain  the  vitality  of  the  newborn 
infant.  In  former  years  considerable  reliance  was  placed  on  a  number 
of  local  hemostatics  to  arrest  the  hemorrhage,  chiefly  the  actual  cau- 
tery, adrenalin,  perchloride  of  iron,  ice  and  compression ;  for  a  time 
also  calcium  chloride  internally  and  sterile,  warm  gelatine  (10  per  cent 
solution,  2  to  5  drams  t.  i.  d.)  hypodermically.  Nowadays,  however, 
all  these  doubtful  procedures  have  been  practically  abandoned. 

Whether  the  hemorrhage  be  due  to  congenital  hemophilia  or  sepsis, 
the  best  results  are  obtainable  from  subcutaneous  injection  either  of 
blood  serum  10  to  20  c.c.  or  whole  blood  (10  c.c.  to  30  c.c.  to  be  with- 
drawn from  the  vein  at  the  bend  of  the  elbow  of  a  donor  or  parent), 
or  both,  after  a  short  interval;  or  from  direct  transfusion.  This  last 
method  is  especially  indicated  in  hemorrhage  associated  with  sepsis; 
but  because  of  the  extreme  diificulty  of  doing  a  transfusion  on  a 
newborn,  owing  to  the  minuteness  of  the  blood  vessels,  the  operation 
should  be  performed  by  an  expert.  It  has  recently  been  shown  that  in 
infants  the  longitudinal  sinus  serves  as  an  excellent,  safe  and  easily 
accessible  route  for  transfusion.  The  baby  is  immobilized  as  for  in- 
tubation,   the   head   is   steadied   by   an    assistant,    and    the    sinus    is 


INJURIES   AND   DISEASES   OP    THE    NEWBORN  231 

reached  by  introducing  (1  or  2  millimeters  deep)  a  needle,  20  or  22 
gauge,  one-half  inch  long.  The  injection  of  human  serum  or  whole 
blood  may  be  repeated  every  four  to  eight  hours.  Where  human 
blood  serum  is  not  obtainable,  horse  or  rabbit  serum  may  be  used  in- 
stead. Transfusion  may  be  performed  by  end-to-end  anastomosis,  by 
the  Lewiston  method  of  citrated  blood,  or  by  the  direct  Unger  method. 
To  meet  the  second  indication  the  reader  is  referred  to  the  in- 
structions given  under  the  "Management  of  Feeble  Vitality  of  the 
Newborn,"  p.  216. 

FUNCTIONAL  DISORDERS  OF  THE  NEWBORN 

(Uric  Acid  Infarct,  Icterus,  Mastitis) 
Uric  Acid  Infarct 

The  urine  of  the  newborn  is  clear  immediately  after  birth,  but 
turns  turbid  soon  after  and  remains  so  for  the  first  four  or  five  days. 
It  contains  bladder  and  kidney  epithelia,  hyaline  and  epithelial  casts, 
and  a  large  quantity  of  urates.  In  consequence  of  the  sudden  altera- 
tion in  the  blood  circulation  there  is  an  excessive  excretion  of  nitrog- 
enous metabolic  products,  and  as  the  newborn  consumes  but  very 
little  water  during  the  first  few  days  of  life,  uric  acid  crystals  and 
ammonium  urate,  instead  of  being  washed  away,  are  retained  in  the 
renal  tubules. 

The  symptoms  accruing  from  this  functional  insufficiency  depend 
greatly  upon  the  degree  of  obstruction  of  the  urinary  tubules.  Or- 
dinarily, gradual  elimination  of  the  uric  acid  and  ammonium  urate 
crystals  occurs  within  a  few  days  without  any  abnormal  manifesta- 
tions, except  restlessness  and  crying  just  before  and  during  the  act 
of  urination,  and  passage  of  small  quantities  of  highly  colored  urine 
showing  brick-red  stains  and  a  fine  granular  deposit  on  the  diaper.  Oc- 
casionally however,  we  find  complete  retention  of  urine,  fever,  and, 
owing  to  irritation  of  the  renal  pelvis,  nephritis  with  its  concomitant 
symptoms  (albuminuria  neonatorum). 

Treatment. — Large  quantities  of  fluids,  hot  baths,  mild  diuretics. 

IJ   Kalii  acetatis    3ss.   I       2.0 

Aq.   fceniculi    giij.   j   100.0 

M. 

S. — 3i  every  hour  if  necessary. 

Icterus  Neonatorum  Catarrhalis 

The  theories  promulgated  to  explain  the  causation  of  icterus  in  the 
newborn  are  so  numerous,  pedantic  and  contradictory,  that  for  the 


232  DISEASES   OF    CHILDREN 

sake  of  clearness,  they  are  best  left  alone.  It  is  perfectly  logical  to 
look  upon  this  common  (in  about  80  per  cent  of  all  newborn  infants) 
and  harmless  phenomenon  as  an  expression  of  the  active  physiologic 
changes  in  the  liver  to  which  all  other  organs  are  subjected  in  the 
first  few  days  of  life.  Hess  believes  the  condition  to  be  due  to  a  con- 
gestion of  the  biliary  capillaries  resulting  from  an  insufficient  ex- 
cretion of  bile  into  the  duodenum.  It  would  seem,  however,  plausible 
to  assume  that  analogous  to  catarrhal  jaundice  in  older  children,  icterus 
of  the  newborn  is  also  a  manifestation  of  gastrointestinal  irritation, 
produced  by  the  sudden  demand  upon  the  digestive  system  to  exer- 
cise functions  hitherto  not  accustomed  to. 

The  yellowish  discoloration  of  the  skin  usually  appears  on  the  second 
or  third  day  on  the  face  and  chest  and  gradually  extends  to  the  ab- 
domen and  extremities  and,  rarely,  also  to  the  scleras.  The  icterus 
runs  an  afebrile,  uncomplicated  course  of  about  two  weeks'  duration. 
Cases  of  a  more  protracted  course  and  presenting  more  or  less  severe 
general  symptoms  should  always  be  looked  upon  as  a  partial  manifes- 
tation of  sepsis  neonatorum.  They  may  also  be  due  to  congenital 
syphilis,  congenital  obliteration  of  the  bile  ducts  (g.  v.),  or  possibly 
also  to  congenital  cirrhosis  of  the  liver. 

Mastitis  Neonatonun 

Moderate  swelling  of  the  mammary  glands  of  the  newborn  and  dis- 
charge of  a  milk-like  secretion  ("witch's  milk")  is  physiologic  in  in- 
fants of  both  sexes.  It  begins  between  the  first  and  third  weeks  of 
life  and  may  persist  for  weeks  without  giving  rise  to  ill  effects.  Oc- 
casionally, however,  as  a  result  of  traumatism  or  infection,  it  may 
terminate  in  acute  inflammation  or  even  suppuration.  In  this  event 
the  breasts  are  red,  swollen  and  painful,  and  may  present  fluctuation 
at  one  or  more  points,  and  constitutional  symptoms,  such  as  restless- 
ness, vomiting,  and  fever. 

If  the  mammary  glands  are  from  the  beginning  not  subjected  to 
meddlesome  interference,  in  short,  are  left  entirely  alone,  there  is 
usually  spontaneous,  gradual  restitutio  ad  integrum.  Should  inflamma- 
tion ensue,  the  breasts  should  be  wrapped  in  oiled  cloths  or  absorbent 
cotton  or  gauze  saturated  with  a  2  per  cent  boric  acid  or  bichloride 
solution  (1:10000),  lightly  painted  with  tincture  of  iodine,  or  covered 
with  emplastrum  belladonnaB  smeared  on  soft  thin  leather.  In  the 
event  of  suppuration,  if  not  relieved  by  spontaneous  evacuation  of 
the  pus,  a  radiate  incision  under  aseptic  precautions  is  indispensable. 

Phlegmonous  inflammation  and  gangrene  are  r^re  complications, 
while  atrophy  of  the  mammary  glands  and  more  or  less  loss  of  func- 
tion may  prove  very  serious  to  girls. 


CHAPTER  V 
DISEASES  OF  THE  ALIMENTARY  TRACT 

DISEASES  OF  THE  MOUTH 

Stomatitis 

Stomatitis  or  inflammation  of  the  mucous  membrane  of  the  oral 
cavity  is  a  more  or  less  contagious  affection  peculiar  to  infancy  and 
early  childhood.  It  varies  in  intensity  from  simple  temporary  catarrh 
to  fatal  gangrene.  It  is  invariably  of  parasitic  origin.  The  degree 
of  severity  of  the  disease  depends  upon  the  pathogenicity  of  the  para- 
site, the  power  of  resistance  of  the  patient,  and  the  promptness  and  ac- 
curacy of  the  treatment. 

Stomatitis  occurs  principally  at  a  time  when  the  child's  health  is 
undermined,  as,  for  example,  during  dentition,  or  synchronously  with 
acute  infectious  diseases.  Even  normally  the  mouth  forms  a  favorable 
nidus  for  cocci,  bacilli,  spirilla,  leptothrix,  and  similar  vegetations, 
and  their  growth  is  surely  enhanced  by  allowing  the  child  to  enjoy 
its  acrid  nasal  discharge;  to  suck  on  dirty  nipples,  toys,  and  eatables; 
by  keeping  its  mouth  and  teeth  filthy;  by  denuding  the  oral  mucous 
membrane  of  its  epithelium  by  brisk  rubbing  in  the  act  of  cleansing, 
and  by  permitting  every  friend  or  kin  to  infect  the  child's  mouth 
by  overindulgence  in  the  art  of  osculation.  Finally,  dental  caries, 
hemorrhagic  affections,  intoxication  from  the  use  of  mercury,  bismuth, 
etc.,  among  many  other  diseased  conditions,  frequently  form  contrib- 
uting causes  of  stomatitis. 

In  accordance  with  the  seat  and  appearance  of  the  lesion  it  is  cus- 
tomary to  distinguish  the  following  varieties  of  the  disease 

1.  Stomatitis  Catarrhalis  (Erythematosa). — Redness  and  slight  tume- 

faction of  several  portions  of  the  mucous  membrane  of  the  mouth, 
coated  tongue  with  prominent  papillse  and  red  tip  and  edges.  Of- 
ten marked  salivation. 

2.  Stomatitis  Mycotica  (Soor,   Thrush,   Sprue). — Probably  due   to   a 

hyphomycete,  the  Monilia  Candida.  Usually  begins  with  a  fine, 
white,  flour-  or  casein-like  deposit  upon  the  slightly  reddened 
tongue  and  buccal  mucous  membrane.  The  deposit  may  be  yel- 
lowish or  blackish  in  color.  If  not  arrested,  the  dots  and  maculae 
coalesce  and  often  extend  to  the  pharynx,  esophagus,  stomach  and 
intestines.    This  is  apt  to  occur  especially  in  atrophic  children. 

233 


234  DISEASES    OF    CHILDREN 

3.  Stomatitis  Maculofibrinosa  (Aphthosa,  FoUicularis,  Herpetiformis). 

— The  causal  microorganism  is  still  undetermined.  Often  begins 
with  small  vesicles.  The  inflamed  mncons  membrane  is  here  and  there 
(usually  the  anterior  part  of  the  mouth)  covered  with  small,  grain- 
to  lentil-sized,  variously  shaped,  yellow,  grayish-yellow,  or  grayish- 
white  foci  surrounded  by  a  dark-red  areola.  By  coalescence  of 
several  follicles,  large  raised  plaques  are  sometimes  observed. 
Fetor  ex  ore. 

4.  Stomatitis  Ulcerosa  (Stomacace). — It  is  attributed  to  the  Bacillus 

fusiformis  and  the  Spirochaete  denticola.  The  lesion  consists  of 
numerous,  grayish,  irregular,  ulcers  with  a  bleeding  base  and  angry- 
looking  areola,  situated  at  first  on  the  red,  spongy  and  painful 
gums,  and,  if  not  arrested,  spreading  to  the  tongue,  cheeks  or  lips 
and  tonsils.  Fetor  ex  ore.  In  bad  cases  also  the  teeth  loosen  and 
the  lymph  nodes  swell. 

This  form  of  stomatitis  differs,  from  the  yellowish  to  greenish,  super- 
ficial, easily  bleeding  ulcers,  known  as  Bednar's  apkthce  (ulcera  ptery- 
goidea),  of  the  newborn  or  young  infant,  by  the  fact  that  the  latter 
appear  symmetrically  on  each  side  of  the  median  raphe  near  the  junction 
of  the  hard  and  soft  palates,  and  are  usually  the  result  of  abrasion  of 
the  epithelium  by  too  strenuous  cleansing  of  the  mouth. 

It  may  occasionally  also  be  mistaken  for  the  exceptionally  ulcerating, 
so-called  ^'epithelial  pearls."  These  innocent  milia-like  dots,  however, 
are  usually  found  only  in  the  newborn,  and  situated  along  both  sides  of 
the  raphe  of  the  palate. 

5.  Stomatitis  Gangrenosa  (Noma  Faciei,   Cancrum  Oris). — It  occurs 

principally  in  cachectic  children,  chiefly  between  two  and  five 
years  old.  It  may  follow  ulcerative  stomatitis  or  acute  exanthem- 
atous  diseases  (measles !)  and  begins  with  a  small,  rapidly  spreading 
brownish,  greenish  ulcer  upon  a  hard,  elevated  base,  on  the  inner 
surface  of  the  cheek,  near  the  angle  of  the  mouth  or  on  the  lips. 
Very  soon  a  black  spot  appears  on  the  outside  of  the  cheek,  sur- 
rounded by  marked  tumefaction  of  that  side  of  the  face  and  the 
submaxillary  glands.  The  cheek  becomes  perforated,  the  edges 
of  the  wound  turn  black,  and  the  sloughing  process  spreads  rap- 
idly so  that  the  whole  thickness  of  the  cheek  has  the  appearance 
of  a  dirty,  greasy  scab,  and  within  a  few  days  may  be  completely 
destroyed.  Also  necrosis  of  the  jaw  and  general  toxemia.  Rapid 
exhaustion. 

In  addition  to  these  definite  varieties  of  stomatitis,  we  occasionally 
meet  with  involvement  of  the  oral  mucous  membrane  as  a  result  of 


PLATE  III 

Stomatitis  Aphthosa  (Advanced  Stage) 

(Courtesy  of  Dr.  John  Zahorsky.) 


DISEASES   OF    THE    ALIMENTARY    TRACT  235 

diphtheritic  or  gonorrheal  infection,  as  also  a  pseudomembranous 
form  arising  from  traumatism  and  subsequent  streptococcic  infection 
of  the  mucous  membrane.  This  last  variety  is  not  rarely  observed 
in  the  newborn,  occasionally  forming  a  partial  manifestation  of  sep- 
sis neonatorum  {q.  v.) 

Mild  or  even  moderately  severe  cases  of  stomatitis  rarely  give  rise  to 
systemic  disturbance,  and  unless  the  local  lesion  is  situated  on  the  lips, 
tongue,  or  gums  and  interferes  with  sucking,  or  chewing,  several  days 
may  pass  before  the  disease  is  detected.  Sometimes  the  patient  is 
feverish  and  restless,  cries  and  refuses  food  in  the  earliest  stage  of 
stomatitis,  but  the  constitutional  symptoms  do  not  stand  in  direct 
ratio  to  the  extent  and  gravity  of  the  local  manifestations.  However, 
with  persistence  of  the  local  symptoms,  sooner  or  later  the  general 
health  participates  in  the  pathologic  process.  Starch  digestion  is 
greatly  impaired  by  the  excessive  loss  of  saliva,  which  almost  inces- 
santly dribbles  from  the  swollen,  reddened,  half-closed  lips,  and  vom- 
iting and  severe  diarrhea  are  frequent  results  of  swallowing  of  the 
putrid  saliva  and  the  decomposing,  more  or  less  ichorous  and  membra- 
nous oral  contents.  These  latter  symptoms,  in  addition  to  the  emacia- 
tion from  refusal  of  food  and  absorption  of  septic  material,  greatly 
delay  convalescence  and  may  lead  to  gradual  or  rapid  exhaustion  and 
fatal  issue.  In  the  absence  of  such  grave  symptoms  and  with  early 
and  careful  treatment,  however,  the  prognosis  is  good  in  all  forms  of 
stomatitis,  except  noma  (75  per  cent  mortality). 

Treatment. — Above  all,  cleanliness  should  be  enforced,  and  the  sooner 
it  is  begun  the  surer  we  are  of  rendering  the  disease  free  from  unto- 
ward consequences.  Strictest  cleanliness  of  the  food,  feeding-bottles 
and  nipples,  cups,  spoons  and  everything  else  coming  in  contact  with 
the  child's  mouth,  should  be  observed.  The  child's  mouth  should  be 
regularly  washed  after  each  feeding,  by  gently  wiping  it  with  absorbent 
cotton  dipped  in  a  2  per  cent  watery  solution  of  boric  acid  or  bicar- 
bonate of  soda.    As  to  general  cleanliness,  see  "Hygiene,"  p.  64. 

In  mild  cases  it  is  usually  sufficient  to  paint  the  affected  parts  once 
a  day  with  a  2  per  cent  solution  of  nitrate  of  silver  and  to  employ 
the  following  mouth  wash  every  two  to  four  hours: 


IJ     Acid  borici, 


4.00 


Sod.   boratis    aa  3j. 

Hydrogen  dioxidi, 

Glycerin!    aa  5j. 

Alcoliolis     3iv. 

Aq.  rosae q.  s.  5iv. 

M. 
S. — To  be  diluted  with  an  equal  quantity  of  water,  as  a  mouth-wash. 


30.00 

15.00 

120.00 


236  DISEASES   OF    CHILDREN 

Should  the  stomatitis  fail  to  yield  to  the  treatment  after  twenty- 
four  to  forty-eight  hours,  more  energetic  measures  should  then  be 
adopted  to  stay  its  destructive  tendencies.  The  strength  of  the  silver 
solution  should  be  doubled,  and  the  mouth  irrigated  every  two  hours 
with  1  per  cent  permanganate  of  potash,  5  per  cent  Labarraciue's 
solution,  14  to  1  per  cent  of  chlorazene  or  Chloramine  T  (Dakin's  anti- 
septic), etc. 

It  is  often  advantageous  to  suspend  milk  feeding  for  a  few  days 
and  to  nourish  the  child  on  broths,  light  cocoa,  cereals,  toast  and  tea, 
pineapple  juice,  etc.  Protracted  illness  demands  active  stimulation  by 
means  of  good  wines  (diluted),  strychnine,  and  compound  tincture  of 
cinchona.  This  may  be  combined  with  the  rhubarb  and  soda  mixture 
to  remedy  gastrointestinal  disturbance  which  is  ever  present  in  cases 
of  long  standing.  In  the  majority  of  instances  even  severe  cases  of 
stomatitis  promptly  respond  to  this  mode  of  treatment.  An  exception 
to  this  rule  is  made,  however,  by  noma, — that  rapidly  advancing  form  of 
necrosis,  which  knows  no  barrier  to  its  destructive,  death-dealing  trail, 
and  often  even  the  knife  fails  to  stay  its  ravages.  At  the  earliest 
possible  moment  the  gangrenous  portion  should  be  destroyed  with  the 
caustic  stick,  nitric  acid  or,  preferably,  with  the  actual  cautery.  Fre- 
quent cleansing  of  the  parts  should  be  continued  day  and  night,  and 
strengthening  food  and  stimulants  administered  at  short  intervals. 
Since  Loeffl.er's  bacilli  are  found  in  a  number  of  cases  of  noma 
faciei  and  vulvae,  diphtheria  antitoxin  (5  to  10,000  units)  should  be 
resorted  to  early  in  the  course  of  the  disease.  Very  often  everything 
fails;  fatal  issue  occurs  either  after  two  or  three  weeks  (sometimes 
when  the  patient  is  apparently  saved)  or,  more  rarely,  suddenly  as  a 
result  of  entrance  of  air  into  the  veins.  Radical  operation  has  recently 
received  enthusiastic  advocacy. 

Dentitio  Difficilis 

(Difficult  Teething) 

As  a  rule,  normal  children  get  their  teeth  without  any  difficulty. 
They  may  show  a  slight  indisposition  in  the  form  of  fretfulness,  dis- 
turbed sleep  and  slight  loss  of  appetite.  If  care  is  being  taken  not  to 
overfeed  the  baby  during  its  teething  period  and  the  mouth  is  kept 
free  from  outside  infection,  there  is  rarely  any  need  for  special 
therapeutic  measures.  On  the  other  hand,  infants  of  low  vitality  and 
more  especially  those  who  had  been  suffering  from  gastroenteric  dis- 
turbances or  rachitis  previous  to  the  eruption  of  a  tooth,  teething, 
particularly  if  several  teeth  come  at  once,  is  very  apt  greatly  to  ag- 


DISEASES    OF    THE   ALIMENTARY    TRACT  237 

gravate  the  diseased  conditions.  But  even  in  these  children  neglect 
in  the  general  care  of  their  health  is  responsible  to  a  great  extent 
for  the  serious  consequences.  Most  people  are  so  strongly  imbued 
with  the  idea  that  teething  is  the  sole  cause  of  gastroenteritis,  bronchi- 
tis, otitis,  and  what  not,  and  that  it  must  be  so  as  a  matter  of  course, 
that  they  complacently  wait  and  watch  for  the  teeth  to  protrude,  and 
seek  no  medical  aid  to  stay  the  ravages  of  the  incidental  ailments.  It 
is  usually  in  these  cases  that  hyperpyrexia  and  convulsions  are  en- 
countered, and  that  remedial  measures  have  to  be  employed  to  facili- 
tate teething,  as  it  were. 

Of  course  there  are  infants  (see  ''Spasmophilia,"  p.  668)  who  will 
get  convulsions,  high  fever,  etc.,  on  the  most  trifling  provocation,  and 
hence  teething  also  is  contributing  its  share  in  this  direction,  but  all 
these  extraordinary  manifestations  are  no  doubt  exceptional. 

The  main  points,  therefore,  are  to  reduce  the  food,  to  keep  the  child 
outdoors,  and  to  avoid  so-called  ''soothing  syrups,"  which  almost  in- 
variably contain  opiates  or  similar  stupefiers  that  depress  the  infant's 
vitality. 

"When  the  gum  is  very  much  swollen  and  the  tooth  visible  directly 
under  the  mucous  membrane,  brisk  friction  (with  rough  end  of  sterile 
teaspoon)  or  even  lancing  of  the  gum  does  no  harm  and  may  relieve 
some  reflex  nervous  symptoms. 

DISEASES  OF  THE  SALIVARY  GLANDS 

Salivation 

Increased  salivary  secretion  is  almost  physiologic  during  first  denti- 
tion, and  is  the  result  of  increased  blood  supply  to  the  oral  mucous 
membrane.  Pathologically  it  is  observed  in  stomatitis,  cretins  and 
other  mentally  deficient  children;  in  helminthiasis  and  mercurial  in- 
toxication. Occasionally  it  is  met  with  in  apparently  healthy  children 
long  after  first  dentition ;  and  in  the  absence  of  any  discernible  cause 
it  is  attributed  to  a  neurosis.  In  view  of  the  harmlessness  of  the 
condition  per  se,  no  special  treatment  is  indicated  except  protection  of 
the  chin  and  chest  against  the  irritating  effect  of  the  constantly  dribbling 
saliva,  and  removal  of  the  causes  wherever  found. 

Ranula 

Retention  cysts,  congenital  or  acquired,  are  not  rarely  observed  in 
children,  and  are  the  result  of  obstruction  of  the  salivary  ducts.  Most 
frequently  a  globular,  usually  unilateral,  tense,  cystic  swelling  is 
found  on  the  floor  of  the  oral  cavity,  sometimes  close  to  the  frenulum. 


238  DISEASES   OF    CHILDREN 

This  tumor  which  is  designated  ranula,  varies  in  size  from  a  pea  to  a 
pigeon's  egg  and  contains  a  thin  or  viscid  fluid.  If  large  in  size,  the 
tumor  interferes  with  suckling,  swallowing  and  breathing,  and  calls  for 
its  incision  and  cauterization,  or  complete  excision. 

Ranula  is  not  to  be  confounded  with  the  peculiar  sublingual  growth 
(Riga's  or  Fede's  disease)  quite  frequently  observed  in  Italy*  among 
nurslings.  This  neoplasm  is  usually  situated  at  the  insertion  of  the 
frenum  lingusB,  attains  almost  the  size  of  a  five-cent  piece,  and  shows  a 
tendency  to  return  unless  completely  extirpated. 

Secondary  Paxotitis 

This  form  of  inflammation  of  the  parotid  gland  may  occur  in  con- 
nection with  acute  infectious  diseases.  It  differs  from  epidemic  mumps 
(q.v.)  in  being,  as  a  rule,  unilateral.  It  heals  spontaneously  within  a 
few  days,  or  ends  in  suppuration,  in  the  latter  event  requiring  operative 
interference. 

DISEASES  OF  THE  TONGUE 

Glossitis 

Aside  from  the  divers  pathologic  conditions  of  the  tongue  ordina- 
rily met  with  in  connection  with  stomatitis,  tonsillitis,  pharyngitis, 
exanthematous  affections,  etc.,  the  tongue  is  subject  to  the  following 
peculiar  diseases: 

1.  Glossitis  Marginalis  Erythematosa. — The  inflammation  is  usually 
limited  to  the  edges  of  the  tongue  which  are  red  and  partially  denuded 
of  epithelium.  It  is  observed  in  artificially  fed  infants,  and  is  probably 
the  result  of  mechanical  irritation  from  the  act  of  sucking,  and  more 
particularly  from  the  constant  use  of  the  "pacifier." 

The  treatment  is  the  same  as  for  mild  stomatitis. 

2.  Glossitis  Areata  Exfoliativa  (Annulus  Migrans,  Ringworm  of  the 
Tongue,  Lingua  Geographica) . — As  a  rule,  it  begins  with  a  brownish 
thickening  at  the  margin  of  the  tongue,  and,  by  gradual  spreading, 
forms  irregular,  circumscribed  lines,  resembling,  as  the  name  indicates, 
a  geographical  map.  Now  and  then  part  of  the  thickened  epithelium 
is  thrust  off,  but  new  places  are  soon  involved,  and  in  this  manner  the 
affection  may  go  on  for  years,  without,  however,  giving  rise  to  ulcera- 
tion of  the  tongue  or  any  constitutional  symptoms.  It  is  not,  as  was 
frequently  supposed,  a  sign  of  syphilis. 

The  treatment  consists  of  cleanliness  and  occasional  painting  with 
a  strong  solution  of  chromic  acid.     (See  "Stomatitis.") 

*Only  a  few  such  cases  have  thus  far  been  observed   in   this  country. 


DISEASES   OP    THE    ALIMENTARY    TRACT 


239 


DISEASES  OF  THE  ESOPHAGUS 

Esophag'itis 

Primary  inflammation  of  the   esophagus   is   comparatively  rare   in 
children,  since  the  principal  cause  of  the  disease  in  the  adult,  i.  e., 


Fig.  57. — Penny  in  esophagus  of  an  infant  readily  extracted  under  the  guidance  of 

the  roentgen  ray. 

corroding  of  the  esophagus  by  caustic  poisons  taken  with  suicidal  in- 
tent, is  of  exceptional  occurrence.  However,  it  is  occasionally  met 
with  in  connection  with  accidental  injuries,  such  as  impaction  of  for- 
eign bodies,  unintentional  swallowing  of  caustics,  etc.,  or  scalding  by  hot 


240  DISEASES   OF    CHILDREN 

fluids.  The  accompanying  symptoms  vary  with  the  extent  of  the  in- 
jury. They  consist  chiefly  of  dysphagia,  tendency  to  vomit,  and  ex- 
pectoration of  bloody,  membranous  masses.  In  severe  eases,  if  the  pa- 
tient at  all  survives  from  the  immediate  effects  of  the  injury  (fre- 
quently fatal  collapse),  the  esophagitis  runs  a  very  protracted  course 
and  produces  secondary  esophageal  strictures  (q.v.). 

Secondary  esophagitis  occurs  as  an  extension  of  inflammatory,  espe- 
cially diphtheritic,  processes  of  the  mucous  membrane  of  the  mouth  and 
pharynx. 

Treatment. — Antidotes  in  cases  due  to  corrosives,  morphine  hypoder- 
mically  for  the  relief  of  pain  and  shock,  ice  collar  to  the  neck  and  ice 
by  mouth  to  subdue  the  inflammation,  and  stimulants  whenever  indi- 
cated. 

Stenosis  Esophagi. — Esophageal  strictures  may  be  congenital  (q.  v.) 
or  acquired,  the  latter  being  the  result  of  esophagitis  (q.  v.).  De- 
pending upon  the  severity  of  the  injury  the  stricture  may  advance 
up  to  total  atresia.  In  children  the  stenosis  is  most  frequently  situ- 
ated in  the  upper  third  of  the  esophagus,  and  may  occasionally  be 
detected  by  esophagoscopy.  Otherwise  the  diagnosis  is  established 
by  introduction  into  the  esophagus  of  an  elastic  catheter  or  whalebone 
provided  with  a  small  olive-shaped  steel  tip.  For  this  purpose  the  pa- 
tient is  placed  in  a  sitting  posture  with  the  head  extended  slightly  back- 
ward. The  oiled  instrument  is  guided  with  the  first  two  fingers  over 
the  dorsum  linguae  and  the  epiglottis  into  the  esophagus. 

In  acquired  stenosis  the  symptoms  usually  appear  about  two  weeks 
after  the  injury  and  consist  chiefly  of  difficult  deglutition  and  gradual 
loss  of  weight.  In  cases  of  stenosis  due  to  compression  of  the  esophagus 
by  diseased  neighboring  organs  or  tumors  the  symptoms  are,  of  course, 
more  gradual  in  their  development  and  more  intricate  in  nature  agree- 
ing with  the  primary  cause. 

Treatment. — Partial  stenoses  often  yield  to  dilatation  by  means  of 
bougies,  provided  the  dilatation  is  continued  two  or  three  times  a  week 
for  at  least  six  months.  The  bougie  is  left  in  place  for  from  five  to 
thirty  minutes.  Occasional  introduction  of  the  bougie  after  apparent 
cure  will  prevent  recurrences.  Great  care  and  patience  are  required  to 
prevent  perforation.  Gavage  and  nutrient  enemata  are  used  if  neces- 
sary. In  severe  and  recurrent  strictures  operative  interference  (esopha- 
gotomy  or  gastrotomy)  are  in  order.  Good  results  are  claimed  from  the 
use  of  thiosinamine :  five  drops  of  a  10  to  15  per  cent  glycerinated 
M^atery  solution  may  be  injected  hypodermically  twice  a  week  in  addition 
to  the  dilatation  previously  spoken  of.  Thiosinamine  may  also  be  given 
by  mouth  (I/2  gr.  t.  i.  d.)  and  applied  locally. 


DISEASES    OF    THE   ALIMENTARY   TRACT  241 

DISEASES  OF  THE  STOMACH  AND  INTESTINES 
General  Etiology 

With  the  recent  advances  in  bacteriology  and  physiologic  chem- 
istry and  corresponding  improvements  in  sanitation  and  infant  feed- 
ing, cow's  milk  no  longer  holds  the  record  of  "WuergengeV  (destroy- 
ing angel)  of  the  poor  innocent  babes.  Indeed,  a  case  of  gastroenteritis 
is  seldom  met  with  which  is  not  primarily  traceable  to  some  gross  error 
of  diet  entirely  independent  of  the  cow's  milk  feeding.  The  sooner  the 
physician  will  appreciate  that  fresh,  unpolluted,  properly  modified  (as 
to  quality  and  quantity),  well  kept,  and  regularly  administered  cow's 
milk  is  not  inimical  (except,  of  course,  in  the  comparatively  rare  cases 
of  so-called  "cow's  milk  idiosyncrasy"  from  birth)  to  good  health  and 
perfect  development  of  the  child,  the  better  will  he  be  prepared  to  re- 
veal the  etiologic  factors  of  the  gastrointestinal  disturbance  and  com- 
bat them! 

On  the  other  hand,  cow's  milk,  especially  in  the  hot  season  of  the 
year,  whether  contaminated  at  the  dairy  or  at  the  filthy  shop  of  the 
remorseless  vendor,  may  form,  like  water,  an  excellent  vehicle  for  the 
dissemination  of  pathogenic  bacteria,  and  for  the  spreading  of  infec- 
tious gastroenteric  affections. 

Whatever  the  vehicle  of  transmission, — be  it  decomposed  milk,  fruit, 
vegetables,  or  meats ;  infected  water,  feeding  bottles  or  nipples,  cups 
or  spoons,  toys  or  fingers;  infectious  discharges  from  the  mouth  or 
nasopharynx,  etc., — careful  investigation  has  established  the  fact 
that  most,  if  not  all,  acute  gastrointestinal  diseases  are  primarily  or 
secondarily  due  to  microbic  invasion  of  the  alimentary  canal,  the  se- 
verity of  the  affection  more  or  less  corresponding  to  the  pathogenicity 
of  the  invading  microorganisms. 

The  bacteria  responsible  for  the  production  of  gastrointestinal  dis- 
eases are  very  numerous.  Streptococci,  the  B.  coli  communis,  B.  dysen- 
teriae  liquefaciens,  (Shiga,  Kruse  and  Flexner)  staphylococci,  B.  in- 
fluenzae, B.  pyocyaneus,  B.  proteus,  among  many  others,  contribute 
their  share  as  etiologic  factors.  The  determination  of  the  specific  germ 
of  each  type  of  gastrointestinal  disease,  however,  is  still  a  matter  of  ex- 
perimental research  and  subject  to  great  diversity  of  opinion. 

Gastroenteric  disorders  in  breast-fed  babies  may  occur,  in  addition  to 
errors  of  diet  and  exposure  to  infection — ^less  frequent  causes  than  in 
hand-fed  babies — as  a  result  of  disturbance  of  the  quality  of  the  breast 
milk  by  disease,  fright,  grief,  privation,  pregnancy,  and  like  influences 
on  the  part  of  the  mother,  or  the  wet  nurse. 


242  DISEASES   OF    CHILDREN 

Finally,  even  in  most  carefully  fed  infants,  gastrointestinal  disorders 
are  occasionally  enconntered  where  the  alimentary  canal  is  functionally 
or  anatomically  defective  from  birth  {e.g.,  pylorus  stenosis),  or  where 
the  infant  is  suffering  from  diseases  of  the  otlier  organs  of  the  body,  or 
is  indisposed  from  the  effects  of  functional  or  organic  alterations  asso- 
ciated with  normal  bodily,  development   (e.  g.,  dentitio  difficilis). 

Stenosis  Pylori  Congenita 

(Pylorospasm) 

Stenosis  of  the  pylorus  may  be  complete  or  partial. 

Complete  atresia  is  extremely  rare  and  invariably  fatal  from  com- 
plete starvation  within  a  few  days  after  birth — sometimes  before  the 
diagnosis  can  be  established. 

Partial  stenosis  of  the  pylorus,  on  the  other  hand,  is  a  comparatively 
frequent  affection  which  not  rarely  terminates  in  recovery,  either 
spontaneously  or  through  medical  and  surgical  treatment.  It  is  dis- 
tinguishable in  two  forms :  True  and  false. 

1.  True  or  hypertrophic  stenosis  is  invariably  due  to  a  congenital  nar- 
rowing of  the  lumen  of  the  pylorus  and  is  associated  with  more  or  less 
primary  hypertrophy  of  the  pyloric  ring  and  secondary  dilatation  of 
the  stomach, 

2.  False  or  spastic  pyloric  stenosis  (pylorospasm)  is  the  result  of  con- 
genital faulty  innervation  of  the  stomach,  or  of  acquired  digestive  and 
nervous  disturbances.  It  is  free  from  primary  hypertrophy  of  the  py- 
loric ring.  Sooner  or  later  secondary  hypertrophy  of  the  muscular  and 
mucous  coats  of  the  stomach  occurs  in  consequence  of  the  increased 
force  required  by  continued  muscular  contraction  of  the  stomach  to 
propel  the  ingesta.  At  a  later  stage  of  the  disease  the  stomach  walls 
lose  their  tonicity  and  dilatation  is  the  usual  consequence. 

The  clinical  picture  of  the  disease  is  very  typical.  The  apparently 
fully  developed  infant  at  birth,  after  a  period  of  wellbeing  of  from  a  half 
to  three  weeks  or  even  longer,  begins  to  vomit  sometimes  after  each 
feeding  or  after  several  feedings.  The  vomiting  rapidly  becomes  very 
violent  in  character,  and  the  contents  of  the  stomach,  which  appear 
greater  {ischocJiymia — retention  of  digested  food)  than  the  child  could 
have  taken  in  one  feeding,  consists  of  a  hyperacid*  mixture  of  mucus, 
digested  and  undigested  food,  free  from  bile,  and  is  explosively  ejected 
(projectile  vomiting).  As  an  immediate  result  of  the  vomiting,  the 
intestinal  tract  remains  empty ;  hence,  absolute  constipation,  (but  in  fact 
only  pseudoconstipation)  or  only  occasional  evacuation  of  a  small  quan- 


*In  two  cases  under  our  observation  there  was  total  achylia  gastrica. 


DISEASES   OF    THE    ALIMENTARY    TRACT 


243 


tity  of  brown,  bile-stained,  foul-smelling  fluid.  The  urine  is  scanty 
and  concentrated.  The  infant  acts  very  hungry,  voraciously  swal- 
lows   a    few    mouthfuls    of    food    but    being    seized    by    sudden    spas- 


Fig.  58. — Pylorus  stenosis  in  a  boy  three  mouths  old  under  observation  of  the 
author  through  the  kindness  of  Dr.  J.  L.  Rubinstein.  Note  almost  complete  closure 
of  pylorus  after  bismuth  test.    Patient  recovered  fully  after  operation. 


244  DISEASES    OF    CHILDREN 

modic  pain,  it  drops  bottle  or  breast,  only  to  grasp  it  again  after  some 
relief  is  obtained.  The  abdomen  is  sunken,  while  the  epigastrium  is 
distended,  and  here  and  there  are  visible  peristaltic  movements  {hyper- 
kinesis)  of  the  stomach,  from  left  to  right.  The  peristalsis  can  be  seen 
and  felt  only  after  the  infant  has  become  greatly  emaciated.  Occasion- 
ally the  peristaltic  movement  is  reversed,  i.  e.,  from  right  to  left.  The 
peristaltic  stomach  wave  is  best  obtained  by  washing  the  stomach  and 
allowing  2  ounces  of  water  to  remain,  or  giving  2  ounces  of  food.  If  the 
patient  is  given  a  pacifier  and  is  then  placed  on  his  back  with  the  light 
favorable  for  observation,  the  wave  phenomenon  will  shortly  appear 
(Kerley).  In  most  cases  a  small  tumor — ^the  hypertrophied  pylorus — is 
palpable  at  the  pyloric  end  of  the  stomach  a  little  above  and  to  the 
right  of  the  umbilicus,  or  lower  down  after  the  stomach  has  become 
very  much  dilated. 

In  early  stages  of  pylorospasm  the  symptoms  are  less  pronounced, 
vomiting  is  less  frequent,  and  the  stools  contain  some  curds  and  hardened 
feces,  but  otherwise  cannot  be  easily  distinguished  from  true  pyloric 
stenosis  except  by  Roentgen-ray  examination.  In  pyloric  obstruction, 
bismuth  subcarbonate  (administered  through  a  tube)  will  fail  to  enter 
the  intestines,  or  do  so  only  after  a  period  of  twenty-four  hours  and  in 
very  minute  quantities.  Less  reliable  is  the  charcoal  test.  This  consists 
in  the  administration  by  the  stomach  tube  of  10  grains  of  charcoal  in  2 
ounces  of  water  and  examining  the  contents  of  the  stomach  for  the 
charcoal  twenty-four  hours  later. 

The  course  of  the  affection  varies  with  the  degree  of  contracture.  In 
the  majority  of  instances  the  true  form  of  the  disease,  if  not  operated 
upon  early,  terminates  fatally  in  from  four  weeks  to  four  months,  with 
symptoms  of  inanition,  acidosis,  and  collapse,  or  pneumonia.  Oc- 
casionally, however,  a  change  for  the  better  occurs  and  slow  recovery 
follows.  This  is  particularly  apt  to  take  place  in  spastic  pyloric  steno- 
sis, especially  if  early  and  properly  treated.  With  these  facts  in  view, 
it  is  extremely  difficult  to  decide  when  and  whether  surgical  inter- 
vention is  indicated.  The  profession  is  greatly  divided  on  this  question. 
The  statistics  adduced  for  and  against  an  operation  seem  to  favor  both 
contentions.  The  surgical  '  *  cures ' '  do  not  always  assure  us  of  their  per- 
manency. A  little  patient  of  mine,  nine  weeks  old,  recently  operated 
upon,  did  well  for  six  days,  but  died  two  days  later  from  the  effects  of 
a  minute  gastrointestinal  fistula.  Two  of  my  patients  were  operated 
upon  apparently  successfully,  but  died  suddenly  a  few  weeks  later.  On 
the  other  hand,  who  can  vouch  for  the  permanency  (remissions  are  not 
rare!)  of  the  medical  "cures,"  and  for  the  correctness  of  the  diagnosis  in 


DISEASES   OF    THE   ALIMENTARY   TRACT 


245 


such  cases!     H.  Lowenberg  offers  the  following  very  valuable  observa- 
tions, as  to  the  type  of  cases  demanding  operative  treatment. 


NONSUKGICAL 

1.  Weight  curve  resembles  curve  of 
continued  fever  with  slight  remissions 
and  elevations.  At  the  end  of  a  week  it 
is  stationary,  or  but  slight  loss  or  gain 
is  recorded. 

2.  General  strength  is  not  materially 
reduced  at  end  of  this  time. 

3.  Bowels  are  constipated  but  move- 
ments are  of  fair  size  and  contain  curds 
or  digested  milk. 

4.  Eecovery  of  considerable  quantity 
of  charcoal  in  rectal  discharges,  al- 
though its  passage  is  delayed. 

5.  Nonrecovery,  or  recovery  of  but  lit- 
tle charcoal  in  the  stomach  washings 
twenty-four  hours  later. 

6.  X-ray  examination  reveals  more  or 
less  bismuth  in  the  small  and  large  in- 
testines. 


7.  Severity  of  vomiting  is  intermittent 
and  often  yields  to  gastric  lavage. 

8.  Constantly   palpable,    except   before 
mittently  so. 


SUEGICAL 

1.  Weight  curve  resembles  the  crisis 
of  a  pneumonia.  End  of  a  week  records 
a  loss  of  8  to  10  ounces  or  more. 


2.  General    strength    fails    rapidly. 


3.  Constipation  absolute  or  nearly  so. 
Movements  are  ordinarily  of  bile- 
stained  mucus,  sometimes  very  small 
amounts  of  milk  feces. 

4.  Nonrecovery  of  charcoal,  or  very 
little  at  end  of  thirty-six  to  forty-eight 
hours  and  continuing  for  many  days. 

5.  Eecovery  of  considerable  quantity 
of  charcoal  in  the  stomach  washings 
twenty-four  hours  or  more  after  admin- 
istration. 

6.  X-ray  pictures  taken  in  series  for 
a  period  of  twenty-four  hours  show  re- 
tention of  bismuth  in  the  stomach,  and 
not  any  or  only  traces  in  the  small  and 
large  intestines.  Bismuth  shadow  has  a 
' '  comet '  '-like    appearance. 

7.  Constant,  and  not  influenced  by  gas- 
tric lavage. 

8.  Constantly  palpable,  except  before 
emaciation  occurs. 


An  operation,  if  indicated,  should  not  be  delayed  until  the  child  is 
at  death's  door.  The  choice  between  divulsion  (Loreta),  pyloro- 
plasty, gastroenterostomy,  posterior  gastrojejunostomy  and  the  Ramm- 
stedt  operation  (splitting  of  the  pylorus  longitudinally  down  to  but 
not  through  the  mucosa),  depends  upon  the  pathologic  condition  of 
each  individual  case,  and  the  judgment  of  the  surgeon. 

In  reviewing  one  hundred  and  seventy-five  cases  of  plyoric  stenosis 
in  which  the  Fredet-Rammstedt  operation  was  performed,  W.  A. 
Downes*  offers  the  following  suggestions: 


•Jour.  Am.  Med.  Assn.,  July  24,   1920. 


246  DISEASES    OF    CHILDREN 

1.  If  the  patient  is  observed  from  the  onset  of  symptoms,  medical 
treatment  may  be  tried  for  a  period  of  not  longer  than  ten  days,  pro- 
vided the  weight  loss  does  not  exceed  20  per  cent  during  this  time.  If,  at 
the  end  of  this  period,  the  child  does  not  show  definite  improvement, 
operative  interference  is  indicated.  Any  patient,  continued  under  medi- 
cal care,  and  suffering  a  relapse  should  be  operated  on  at  once. 

2.  All  cases  in  which  there  is  a  history  of  a  period  of  ten  days  or 
longer  in  which  the  data  as  to  previous  weight  are  lacking — and  in 
which  the  patient  is  not  in  very  good  condition — should  immediately  be 
classed  as  surgical. 

3.  The  mortality  among  patients  coming  to  operation  within  four 
weeks  from  the  onset  of  symptoms  is  less  than  8  per  cent. 

4.  The  results  following  the  Frcdet-Rammstedt  operation  are  perma- 
nent and  the  cure  complete. 

The  Rammstedt  operation  is  highly  recommended  by  E.  Feer.  Du- 
four  and  Fredet  have  collected  36  cases  operated  by  the  Rammstedt 
method  with  9  deaths,  Kerley  reports  26  cases  with  4  deaths,  and 
believes  that  operation  by  the  Rammstedt  method  will  insure  a  mor- 
tality of  only  5  per  cent  in  patients  who  have  not  vomited  more  than 
two  weeks,  provided,  of  course  that  adequate  after-care,  which  in- 
cludes the  use  of  breast  milk,  is  supplied.  He  recommends  the  fol- 
lowing postoperative  management,  as  evolved  by  Holt  and  W.  L. 
Downes.  The  infant  is  wrapped  in  a  warm  blanket  before  leaving 
the  operating  room  and  when  in  bed  is  surrounded  by  hot  water 
bottles  outside  the  blanket.  For  an  hour  or  two  following  the  operation, 
the  head  of  the  bed  is  kept  lowered  to  prevent  aspiration  of  mucus  into 
the  larynx.  This  is  absolutely  necessary  while  the  infant  is  still  under 
the  influence  of  the  anesthetic.  When  nourishment  is  commenced,  the 
head  of  the  bed  is  raised  to  a  level  position.  Ten  or  twelve  hours  later 
the  patient  is  placed  in  a  semierect  position,  which  tends  to  prevent  re- 
gurgitation of  food  and  permits  the  more  easy  escape  of  gas. 

As  soon  as  the  patient  is  placed  in  bed,  a  hypodermoclysis  of  120 
c.c.  of  physiologic  sodium  chloride  solution  is  given,  and  if  the  condition 
is  poor,  a  hypodermic  of  5  minims  of  epinephrin,  1:1,000,  is  given  and 
repeated  in  from  four  to  five  hours.  Dilute  whiskey,  5  minims  every 
three  hours  for  the  first  five  or  six  days,  has  proved  of  great  value. 
Transfusion  in  a  few  cases  of  collapse  has  been  of  material  benefit,  from 
80  to  120  c.c.  of  blood  from  either  parent  being  given  preferably  into 
the  median  basilic  vein. 

One  and  one-half  hours  after  operation,  provided  the  patient  has 
sufficiently  recovered  from  the  anesthetic,  10  c.c.  of  water  are  given,  and 
one  and  one-half  hours  later,  4  c.c.  of  barley  water  and  4  c.c.  of  breast 


DISEASES    OF    THE   ALIMENTARY    TRACT  247 

milk.  Two  hours  later,  8  c.c.  of  breast  milk  and  4  c.c  of  barley  water 
are  given.  Breast  milk  is  then  given  every  three  hours,  alternated  with 
water,  and  gradually  increased  in  amount  so  that  at  the  end  of  forty- 
eight  hours  about  30  c.c.  are  given  at  a  feeding,  with  4  c.c.  of  barley 
water.  The  barley  water  is  then  discontinued,  and  on  each  successive  day 
the  amount  of  milk  permitted  is  increased  5  c.c.  at  a  feeding,  so  that  by 
the  eighth  day  following  the  operation  the  patient  is  having  60  c.c.  every 
three  hours.  On  the  third  day  the  intervals  of  feeding  at  night  are 
lengthened  to  four  hours,  so  that  seven  feedings  are  given  instead  of 
eight.  By  the  time  the  baby  is  taking  60  c.c.  of  breast  milk  at  each  feed- 
ing, he  may  be  put  to  the  breast  once.  The  baby  is  weighed  before 
nursing  and  at  intervals  of  three  minutes  until  he  has  nursed  60  c.c. 
from  the  breast.  The  following  day  three  nursings  are  allowed,  so  that 
by  the  eleventh  or  twelfth  day  the  patient  is  nursing  entirely  and  is 
able  to  leave  the  hospital.  Measurement  of  food  during  the  nursing 
must  be  kept  up  one  week  later  by  carefully  weighing  the  baby  both 
before  and  after  nursing.  For  one  month  or  longer  a  wet  nurse  is  ad- 
visable if  the  mother  is  not  able  to  nurse  her  child. 

In  well-nourished  infants,  a  sponge  bath  is  given  daily  until  the 
wound  is  completely  healed.  In  emaciated  children,  an  oil  rub  is  pref- 
erable until  such  time  as  the  tendency  to  subnormal  temperature  has 
passed. 

In  cases  of  vomiting  due  to  accumulation  of  gas  in  the  stomach,  the 
child  should  be  raised  to  an  upright  position  after  feeding.  If  this 
does  not  suffice,  a  soft  rubber  catheter  may  be  passed  into  the  stomach 
before  each  feeding.  If  still  persistent,  gastric  lavage  may  be  employed. 
One  teaspoonful  of  castor  oil  is  usually  given  twenty-four  hours  after 
operation  if  there  have  been  no  stools.  There  should  be  from  two  to 
three  stools  a  day.  If  they  are  more  frequent,  protein  milk  may  be 
substituted  for  three  or  four  breast  feedings. 

The  wound  is  covered  with  a  narrow  fold  of  sterile  gauze  held  in 
place  by  adhesive  strips.  It  is  not  disturbed  for  four  or  five  days,  unless 
some  indication  arises.  The  stitches  are  removed  on  the  ninth  or  tenth 
day. 

The  nonsurgical  treatment  of  congenital  pyloric  stenosis  must  be  car- 
ried out  systematically  and  faithfully.  Whenever  possible,  the  infant 
should  be  fed  on  woman's  milk,  (after  removal  of  fat),  preferably  with  a 
spoon  or  tube,*  in  order  to  gauge  the  amount  of  food  consumed,  and  possi- 
bly retained,  by  the  infant  and  also  to  avoid  contractions  of  the  stom- 
ach by  the  act  of  sucking.     The  amount  of  feeding  should  not  exceed 


*P.    Hertz    (Ugeskr.    f.    Laeger,    June    13,    1918)    recommends    duodenal    feeding   by    means    of 
a  Nelaton  catheter.  No.  18  or  19,  giving  as  much  as  2  to  3  ounces  at  each  feeding. 


248  DISEASES   OF    CHILDREN 

one  ounce,  but  may  be  given  every  hour  or  two,  so  as  to  sustain 
the  child's  vitality.  Modified  or  predigested  milk  may  be  administered 
instead  of  woman's  milk  if  the  latter  is  not  readily  obtainable.  In  view  of 
the  fact  that  almost  two-thirds  of  the  cases  of  pyloric  stenosis  thus  far 
reported  were  breast-fed  babies,  one  is  tempted  to  recommend  fat-free 
cow's  milk  feeding  as  a  therapeutic  or,  at  least,  as  a  prophylactic  meas- 
ure against  pyloric  stenosis.  Indeed,  following  the  temptation  in  2  of  my 
own  cases,  I  was — perhaps  accidentally — rewarded  with  happy  results. 
May  I  venture  to  suggest  that  the  large  curd  of  cow 's  milk  tends  mechan- 
ically to  dilate  the  contracted  pyloric  orifice  ?  and,  furthermore,  that  the 
fat  breast-milk  is  possibly  a  cause  of  pylorospasm? 

Reduction  in  the  frequency  of  the  attacks  of  vomiting  and  in  the 
amount  ejected  forms  the  first  and  best  indication  of  improvement  in 
the  condition.  Next  to  careful  feeding,  systematic  washing  of  the  child's 
stomach  serves  as  the  sheet-anchor  in  the  therapeusis  of  congenital  py- 
loric stenosis.  It  should  be  practiced  at  least  twice  a  day  with  plain,  cool 
(70°  to  80°  F.)  water,  occasionally  adding  a  small  amount  of  bicarbon- 
ate of  soda  to  neutralize  the  hyperacidity  of  the  stomach.  The  washing 
should  be  continued  until  the  water  returns  clear.  The  effects  of  the 
lavage  are  the  removal  of  decomposing  substances  from  the  stomach, 
arrest  of  fermentation  and  the  allaying  of  pain  and  spasm.  For  the  lat- 
ter purposes,  prolonged  warm  baths  and  hot  compresses  to  the  epigastric 
region  are  also  very  useful.  To  counteract  the  excessive  loss  of  fluids, 
a  daily  enteroclysis  or  hypodermoclysis  is  of  advantage.  Internal 
medication  is  of  little  value,  except  anodynes  for  the  relief  of  pain 
and  spasm.  For  this  purpose  minute  doses  of  codeine  with  or  without 
belladonna  may  be  administered  in  the  form  of  suppositories. 

S.  V.  Haas  {Aim.  Jour.  Dis.  Cliild.,  May,  1918)  prefers  atropine  owing 
to  its  paralyzing  effect  on  the  vagus  nerve  endings.  In  the  course  of 
twenty-four  hours  he  administers  from  1/50  to  1/25  of  a  grain  with  an 
extreme  of  1/16  of  a  grain,  divided  among  the  whole  day's  feedings. 

Skillful  nursing,  privately  or  in  a  hospital,  should  be  insisted  upon. 

I.  Acute  Gastroenteritis 

(Indigestion,  Dyspepsia) 

Classiiicatioii 

In  accord  with  the  aforementioned  general  etiology  (see  p.  241) 
gastrointestinal  disease  in  infants  and  young  children  may  be  classi- 
fied as  follows : 

1.  Dyspepsia  ex  aliment atione,  or  faulty  assimilation  of  the  food,  as  a 
result  of : 


DISEASES   OF    THE   ALIMENTARY   TRACT  249 

A.  Overfeeding  or  too  frequent  feeding  in  general,  or 

B.  Overfeeding  with  a  milk  mixture  containing  too  much  of: 

a.  Fat,  b.  Carbohydrates,  c.  Proteins. 

2,  Dyspepsia  ex  infectione,  due  to : 

A.  Direct  infection  of  the  intestinal  tract,  (enteral). 

B.  Indirect  infection  (parenteral),  i.e.  secondarily  to  other  diseases. 

3.  Dyspepsia  ex  constitutione,  in  consequence  of: 

A.  Congenital  deficiencies 

a.  Organic,  e.  g.,  pylorus  stenosis,  megacolon. 

b.  Functional  or  constitutional  dyscrasia,  e.  g.,  exudative  diathesis. 
As  the  other  varieties  of  gastrointestinal  affections  are  fully  described 

in  other  parts  of  the  book  (see  pp.  521,  522)  we  will  here  limit  our  dis- 
cussion to  the  infectious  gastroenteric  affections. 

Occasional  vomiting  and  diarrhea,  occurring  as  a  result  of  unusual 
overloading  of  the  stomach,  too  hasty  feeding,  the  partaking  of  indi- 
gestible articles  of  food  (raw,  unripe  fruit,  peels  and  parings),  or  for- 
eign bodies,  exposure  to  sudden  atmospheric  changes  and  undue  excite- 
ment, etc.,  are  not  rarely  observed  in  otherwise  apparently  healthy, 
well-nourished  children,  and  if  of  brief  duration,  are  of  no  special  clin- 
ical significance.  These  attacks  may  even  be  accompanied  by  fever, 
mild  cerebral  irritation,  colic,  etc.,  and  yet  remain  outside  the  domain 
of  pathology,  or  represent  an  affection  which  is  generally  spoken  of  as 
simple  indigestion  or  the  first  stage  of  gastroenteritis.  By  avoiding 
further  transgressions  of  the  ordinary  dietary  and  hygienic  rules,  and 
by  removing  the  causal  obnoxious  influences,  recovery  is  usually  prompt 
and  permanent. 

If,  however,  the  vomiting  and  diarrhea  persist  or  recur  at  frequent 
intervals;  if  the  child  loses  its  appetite  and  some  of  its  weight;  if  its 
tongue  becomes  heavily  coated,  its  abdomen  greatly  distended  and  its 
general  health  more  or  less  seriously  impaired ;  if  the  infant  suffers  from 
severe  abdominal  pain  after  each  feeding  and  vomits  part  of  the  food 
consumed  and  some  mucus  and  bile ;  finally,  if  the  stools  rapidly  increase 
in  number  and  consist  of  masses  of  undigested  food,  of  bad  color  and 
offensive  odor,  a  symptom-complex  develops  which  represents  the  second 
stage  of  gastroenteritis  and  is  generally  described  as  gastrointestinal 
catarrh  or  dyspepsia. 

Ordinarily  these  manifestations  set  in  insidiously,  and,  if  not  promptly 
arrested,  grow  worse  gradually,  arousing  little  if  any  anxiety  on  the 
part  of  those  in  charge  of  the  baby,  or  are  lost  sight  of,  sometimes  because 
of  coincident  "teething"  (with  the  laity  the  presumptive  cause  of  all 
ills),  until  there  is  a  sudden  aggravation  of  the  condition — superven- 
tion of  the  third  stage  of  the  disease. 


250  DISEASES   OF    CHILDREN 

In  this  stage,  gastroenteritis  assumes  a  very  acute  course.  It  is  mani- 
fested by  violent  vomiting,  excessive  thirst ;  frequent,  thin  watery,  brown- 
ish, greenish,  and  later  colorless  or  blood-stained  stools.  The  vomitus 
is  acid  in  reaction,  bile  stained,  and  offensive  in  odor.  The  bowel  move- 
ments vary  between  ten  to  fifteen  in  twenty-four  hours,  are  preceded 
and  followed  by  griping  pain  and  tenesmus.  The  child  is  very  restless, 
feverish,  sleepless,  and,  with  the  symptoms  persisting  a  few  days,  rapidly 
loses  in  weight,  and  sinks  into  a  state  of  collapse,  followed  by  convul- 
sions, coma  and  death.  More  favorable  cases  may  improve  under 
energetic  treatment  (see  "Cholera  Infantum,"  p.  251),  or  linger  for 
weeks  or  months,  frequently  suffering  from  intense  exacerbations  of 
the  attacks,  and,  finally,  either  recover  after  tedious  convalescence  or 
die  from  inanition  or  complications. 

Cholera  Infantum 

(Summer  Complaint) 

Closely  allied  to  the  gastroenterocolitis  just  described  (though  possibly 
differing  as  to  the  exciting  microorganism — probably  the  dysentery  ba- 
cillus, but  also  the  gas  bacillus  or  streptococcus),  and  probably  repre- 
senting only  a  severer,  "fulminating"  form  of  the  same  disease,  is  the 
so-called  infantile  "summer  complaint"  or  cholera  nostras  s.  infantum. 
It  usually  rages  in  epidemic  form  during  the  hot  summer  months,  espe- 
cially among  bottle-fed  infants  and  those  exposed  to  bad  hygienic  con- 
ditions, but  occurs  sporadically  also  at  other  seasons  of  the  year.  As 
with  other  contagious  and  infectious  diseases,  previous  ill  health  serves 
as  an  active  and  favorable  predisposing  cause  also  in  this  destructive 
affection,  the  acute  and  grave  symptoms  ordinarily  supervening  upon 
a  latent  period  of  indisposition  of  variable  duration. 

The  attack  ushers  in  suddenly  with  vomiting,  diarrhea  and  prostra- 
tion. The  vomiting  is  more  or  less  projectile  in  character  and  occurs 
especially  immediately  after  drinking.  The  evacuations  range  between 
fifteen  to  thirty,  or  more,  in  twenty-four  hours,  are  at  first  fecal  in 
consistency  and  odor,  but  soon  turn  very  watery,  serous,  light  yellow 
or  greenish  in  color,  and  occasionally  are  mixed  with  blood-streaked 
mucus.  The  abdomen  is  often  trough-shaped  and  but  slightly  sensi- 
tive to  pressure.  The  thirst  is  intense;  the  tongue  dry,  brown  or 
black  and  cracked,  irrespective  of  the  degree  of  temperature,  which  is 
rarely  very  high.  Owing  to  the  excessive  loss  of  fluids,  the  urine  is 
very  scanty  and  often  contains  a  moderate  amount  of  albumin. 

As  the  disease  progresses  the  child  perceptibly  loses  in  weight,  from 
hour  to  hour;  its  face  is  pinched,  its  fontanelles,  temples  and  eyes 


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DISEASES   OF    THE   ALIMENTARY   TRAOT"  '-  ,'     .    /    r  251 

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are  deeply  sunken;  its  extremities  are  qopl  and  blue;  the  heart  beat 
and  respiration  barely  audible — in  short,  the  child  is  in  a  state  of 
profound  collapse.  Apathy,  somnolence,  convulsions  and  death  then 
follow  in  rapid  succession ;  the  younger  the  child,  the  earlier,  as  a  rule, 
the  fatal  termination.  The  latter  is  sometimes  preceded  by  a  state  of 
hydrocephaloid — a  condition  variously  ascribed  to  cerebral  anemia  or 
hyperemia,  edema  of  the  meninges  and  uremia,  and  presenting  the  fol- 
lowing symptom-complex :  First  stage,  fever,  restlessness,  jactitations,  and 
insomnia,  flushed  face,  strong  and  bounding  pulse ;  second  stage,  sub- 
normal temperature,  cold  extremities,  feeble,  irregular  pulse  and  respi- 
ration, apathy,  sopor  and  coma. 

The  disease  having  reached  this  grave  stage,  it  offers  a  very  bad  prog- 
nosis ;  few  children  manage  to  survive  so  violent  an  attack.  Some  of  the 
few  who  do,  are  apt  to  succumb  later  to  complicating  nephritis,  pneu- 
monia, cerebral  sinus  thrombosis,  peritonitis  and  the  like. 

Convalescence  is  very  tedious  even  in  the  absence  of  complications, 
and  a  great  many  children  remain  decrepit  for  life ;  chronic  otitis  media, 
xerosis  of  the  cornea  and  panophthalmia  often  adding  to  their  share  of 
misery. 

With  such  sad  prospects  in  view  after  the  gastrointestinal  affection 
is  fully  established,  the  urgency  of  early  and  energetic  prophylaxis  and 
treatment  can  readily  be  appreciated. 

Treatment. — To  prevent  the  graver  forms  of  gastroenterocolitis  we 
must  promptly  remove  the  causes  and  effects  of  the  mildest  symptoms 
of  the  disease.  Attention  to  every  detail  of  rational  feeding  and 
personal  hygiene  and  strictest  cleanliness  of  the  child's  living  rooms, 
feeding  utensils,  wearing  apparel,  and  of  all  other  things  coming  in 
direct  contact  with  the  patient  are  the  surest  means  of  prevention.  As 
in  the  majority  of  instances,  the  pathogenic  bacteria  enter  the  in- 
fantile alimentary  tract  with  infected  milk  or  water,  these  should, 
especially  in  the  summer  months,  be  sterilized  or  even  boiled,  regard- 
less of  the  temporary  arrest  of  gain  in  weight  that  is  concomitant  with 
such  feeding — a  puny  baby  on  the  lap,  rather  than  a  fat  one  in  the 
grave !  Weaning  of  the  baby  and  other  innovations  during  the  hot 
summer  months  should  be  avoided.  Lengthy  voyages,  exacting  pro- 
longed disturbance  of  rest,  sleep,  and  improper  feeding  should  be 
interdicted.  On  the  other  hand,  a  sojourn  in  the  country  (inland, 
mountains,  or  seashore)  should  be  encouraged.  Last  but  not  least 
in  importance  as  a  prophylactic  measure  is  the  practice  of  whole  or 
partial  breast  feeding  of  infants  under  one  year  of  age,  unless  counter- 
manded by  definite  contraindications. 


252  ^  R  G4  J  DISEASES   OF    CHILDREN 

[  1  ^)i0  adtive  tr^tment  should  begin,  as  already  suggested,  with  the 
earliest  inception  of  the  gastrointestinal  disorder.  Regulation  of  diet 
is  our  most  efficient  therapeutic  measure,  and  is  almost  invariably  at- 
tended by  improvement  in  the  child's  condition,  if  it  is  begun  with  a 
few  hours'  starvation  of  the  patient  and  prompt  cleansing  of  the  ali- 
mentary tract  of  its  obnoxious  contents.  Feeding,  breast  or  bottle, 
should  at  once  be  suspended  until  such  time  as  exigencies  for  resump- 
tion of  feeding  shall  demand.  In  the  meantime,  especially  in  the  ab- 
sence of  strong  contraindications,  such  as  violent  vomiting,  the  infant 
should  receive  small  quantities  of  hot  or  cold  pure  water  or  a  light 
infusion  of  black  tea,  sweetened  with  saccharin.  Recurrent  vomiting 
calls  for  prompt  attention,  especially  because  of  its  fearfully  exhaust- 
ing effects,  but  also,  because  it  greatly  hinders  in  the  administration 
of  suitable  medication.  Ordinarily  vomiting  can  be  controlled  by  ''ice- 
sand,"  minute  doses  of  calomel  with  large  doses  (gr.  x)  of  bicarbonate 
of  soda;  bismuth  and  cerium  oxalate;  tincture  of  iodine  (in  1/30  of  a 
drop  doses,  to  be  repeated  every  hour  or  two)  ;  and,  if  all  else  fail,  lavage. 
In  hospital  practice  the  order  of  these  therapeutic  suggestions  is  usually 
reversed,  i.  e.,  lavage  is  usually  resorted  to  first,  and,  as  a  rule,  with 
immediate  relief  to  the  patient.  In  private  practice,  however,  one  often 
meets  with  objections  on  the  part  of  parents,  and  hence  is  obliged  pri- 
marily to  "medicate."  Lavage  should  be  supplemented  by  enteroclysis 
and,  with  the  vomiting  checked,  also  by  a  small  dose  of  castor  oil. 

This  mode  of  treatment  generally  suffices  to  arrest  gastrointestinal 
affections  of  moderate  severity.  Where  the  diarrhea  persists,  we  are 
often  called  upon  to  administer  an  astringent  mixture  like  the  follow- 
ing: 

!^     Bismuthi  subcarbonatis, 

Mist,  cretae  comp., 

Syr.  rhei  aromat., 

Glycerin., 

Aq.  menthae  pip aa  3ij  8.00 

Aq.  destil q.  s.  ad  f gij.      60.00 

M. 
S. — One  teaspoonful  every  two  hours  for  a  child  one  year  old. 

The  camphorated  tincture  of  opium  may  be  added  for  the  relief  of 
pain.  After  complete  cessation  of  vomiting,  we  may  resume  feeding, 
first  with  small  quantities  of  toast-  or  barley-water  or  dextrinized 
gruel  (cereo),  and  several  hours  later,  diluted  protein  milk  (1  ounce 
of  the  milk  with  an  equal  or  a  larger  quantity  of  water,  and  later 
cereal  water).    After  the  diarrhea  has  been  arrested,  the  feeding  with 


DISEASES   OF    THE   ALIMENTARY   TRACT  253 

breast  milk  or  modified  cow's  milk  in  small  and  gradually  larger  quan- 
tities, may  be  resumed. 

In  fulminating  attacks  of  gastroenterocolitis,  where  the  bacterial 
toxins  so  violently  overwhelm  the  infantile  organism  and  produce  intense 
shock,  the  treatment  must  be  very  prompt  and  more  heroic.  In  the 
initial,  febrile  stage,  after  a  single  but  thorough  irrigation  of  the  stom- 
ach and  bowels,  the  little  patient  is  given  1/50  of  a  grain  of  morphine 
and  1/500  of  a  grain  of  atropine  hypodermically,  is  wrapped  in  warm 
blankets  and  sent  outdoors — ^wherever  a  good  breath  of  air  is  obtainable 
— preferably  to  the  seashore.  After  responding  favorably,  the  treatment 
is  followed  up  in  the  manner  previously  outlined  for  less  severe  cases. 

In  the  algid  stage,  where  the  child  is  at  death's  door — wasted,  cold, 
blue,  rigid  and  lifeless,  in  short  in  profound  collapse — powerful  stimu- 
lation is  in  order.  Thus,  a  hot  bath  with  brisk  rubbing  of  the  body;  a 
hot  (110°  F.)  high  enema  (injected  slowly  so  as  to  be  retained),  hot  water 
by  mouth,  hypodermic  administration  of  sterile  camphorated  oil  (8 
drops  of  a  15  per  cent  solution),  strychnine  (gr.  1/60  to  1/30),  caffeine 
sodium  benzoate  (1  grain),  or  whiskey  (10  drops),  hypodermoclysis  (1  to 
6  ounces  of  a  0.9  per  cent  hot  sterile  salt  solution),  and  injection  of 
normal  saline  in  the  peritoneal  cavity  or  longitudinal  sinus  (see  p.  209). 
As  the  patient  improves  a  milder  course  of  treatment  is,  of  course,  re- 
sorted to.  The  physician  should  not  be  deceived,  however,  by  those 
apparent  improvements,  as  they  not  rarely  precede  fatal  termination, 

II.  Subacute  and  Chronic  Gastroenterocolitis 

Exhausted  by  the  paralyzing  action  of  the  virulent  bacterial  toxins ; 
wasted  and  weakened  from  the  excessive  loss  of  body  fluids  and  the 
strict  starvation  diet  enforced  during  the  acute  course  of  the  disease, 
the  little  patient  rarely,  if  ever,  emerges  in  a  state  of  health  capable 
of  exercising  its  digestive  organs  to  their  normal  capacity.  On  the 
contrary,  convalescence  usually  proceeds  at  a  very  slow  pace,  and  is 
frequently  interrupted  by  milder  exhibitions  of  gastrointestinal  in- 
digestion, which,  if  not  promptly  yielding  to  energetic  treatment, 
eventually  lead  to  chronic  involvement  of  the  alimentary  tract. 

The  mucosa  of  the  stomach  and  bowels,  especially  of  the  ileum  and 
colon,  undergoes  gradual  thickening,  and  often  ulceration.  The 
mesenteric  glands  are  more  or  less  enlarged,  and  on  cross-section  are 
partly  red  and  partly  yellowish  gray  in  color  and  sometimes  caseated. 
In  very  protracted  cases  the  mucosa  and  its  follicles  are  atrophied,  and 
the  lungs,  liver  and  heart  are  in  a  state  of  inflammation  and  degenera- 
tion. 


254 


DISEASES   OF    CHILDREN 


The  bowel  movements  continue  to  be  frequent  (four  or  five  times  in 
twenty-four  hours).  The  stools  are  thinner  than  normal,  are  mixed 
with  particles  of  undigested  food,  mucus,  and  blood.  The  abdomen 
is  flat,  sometimes  deeply  sunken,  and  through  its  thin  and  wasted  wall 
one  can  readily  palpate  the  greatly  enlarged,  "ropy,"  mesenteric 
glands.  The  child's  appetite  is  capricious,  often  very  good,  and 
contrasts  strongly  with  the  persistent  loss  of  weight.  The  tongue 
is  coated  and  flabby,  its  edges  are  red  and  indented  by  the  teeth  or 


Fig.  50. — Chronic  gastroenteritis  in  an  infant  ten  weeks  old.     (See  Fig.  .56.) 


gums,  and  here  and  there  covered  by  an  aphthous  deposit.  Slight  in- 
discretions in  the  dietary  are  promptly  followed  by  vomiting  and  diar- 
rhea. Chemical  examination  of  the  contents  of  the  stomach  discloses 
marked  diminution  of  hydrochloric  acid. 

The  course  of  chronic  gastroenteritis  varies  in  individual  cases. 
Some  infants,  especially  those  in  whom  the  chronic  affection  followed 
upon  the  acute  form,  who  remained  free  from  grave  complications  and 
retained  some  vitality,  often  unexpectedly  show  marked  improvement 


DISEASES   OF    THE    ALIMENTARY    TRACT  255 

with  the  setting  in  of  cooler  weather,  and  regain  their  health  fully 
within  a  few  weeks. 

In  another  group  of  cases  recovery  is  less  rapid.  Improvement  al- 
ternates with  aggravation  of  the  condition,  but,  finally,  the  infant  ex- 
tricates itself  barely  alive,  with  a  load. of  sequelae  (e.g.,  rachitis)  which 
keep  it  in  a  state  of  decrepitude  for  many  months  and  even  years  there- 
after. 

In  still  another  group  of  cases  all  therapeutic  efforts  utterly  fail 
to  effect  a  cure.  The  child's  face  has  a  pallid,  earthy  tint,  and  senile 
expression;  the  skin  is  dry  and  hangs  in  folds;  the  fontanelles  and 
temples  are  depressed,  and  after  a  period  of  several  weeks  or  months 
the  infant  finally  succumbs  either  slowly  with  symptoms  of  cerebral 
anemia  and  heart  failure  or  suddenly  during  an  attack  of  eclampsia. 
The  fatal  termination  is  frequently  enhanced  by  complicating  pulmo- 
nary (passive-  or  bronchopneumonia)  and  renal  (colicystitis,  pj'clitis, 
etc.)  affections;  skin  (ecthyma,  furunculosis),  ear  and  mouth  infec- 
tions, or  intercurrent  acute  communicable  diseases  (exanthemata). 

At  best  the  prognosis  is  very  grave  (30  per  cent  mortality),  espe- 
cially so  in  infants  reared  under  bad  hygienic  conditions,  in  want  and 
misery,  and  in  those  born  with  lowered  vitality  and  congenital  defects. 

However,  no  effort  should  be  spared  to  save  an  infant  that  is  ap- 
parently hopelessly  lost,  for  just  in  chronic  gastroenteritis  the  unex- 
pected sometimes  happens — recovery  takes  place  at  a  time  when  re- 
lief by  death  is  prayed  for. 

Treatment. — The  patient  should  be  removed  from  insanitary  sur- 
roundings and  intrusted  to  the  care  of  some  one  who  will  obey  orders 
rather  than  use  her  own  judgment  and  that  of  the  many  "good  and  ex- 
perienced" neighbors.  Be  it  remembered,  that  only  too  often  change 
of  nurse  (with  her  gross  negligence  and  stubborn  interference)  has 
saved  many  a  hapless  baby!  Regulation  of  diet  is  most  essential.  No 
hard  and  fast  rule,  however,  can  be  laid  down  in  this  direction.  We  must 
feel  our  way  in  every  individual  case.  It  is  always  a  good  plan  in  bot- 
tle-fed babies  to  begin  treatment  with  discontinuance  of  the  milk  for  a 
day  or  two  and  thorough  cleansing  of  the  alimentary  tract  by  a  laxative, 
lavage  and  enteroclysis.  In  the  meantime  the  patient  should  be  fed 
on  thin  barley  water,  acorn  cocoa,  a  light  infusion  of  black  tea,  albu- 
min water,  diluted  protein  milk,  and  perhaps,  a  small  quantity  of  freshly 
boiled,  fat-free  chicken  or  mutton  soup.  As  soon  as  the  stools  diminish 
in  frequency  and  improve  in  consistency,  we  resume  milk  feeding  in 
very  high  dilution.  For  a  child,  let  us  say  of  six  months,  one  table- 
spoonful  of  fat-free  milk  to  seven  tablespoonfuls  of  barley  or  rice  water, 


256  DISEASES    OF    CHILDREN 

to  be  given  every  three  hours,  may  be  prescribed,  and  directions  given 
daily  to  increase  the  quantity  of  milk  until  the  percentage  of  1  to  2  has 
been  reached ;  then  gradually  the  total  quantity  at  the  last  ratio  (i,  e., 
1  to  2)  is  augmented,  until  6  ounces  are  obtained  for  each  feeding. 
Should  the  milk  mixture  disagree,  a  weaker  milk  mixture  is  resorted 
to,  or  milk  is  again  discontinued,  falling  back  upon  albumin  milk  with 
cereals,  albumin  water  and  tea.  Some  infants  do  well,  at  least  for  a 
time,  on  condensed  milk  and  barley  water;  others,  especially  those  suf- 
fering from  the  so-called  "fat-diarrhea,"  improve  rapidly  on  albumin 
milk,  skimmed  milk  or  whey,  and  still  others  (older  ones),  who  cannot 
tolerate  milk  in  any  form,  get  along  on  toast  and  tea,  acorn  cocoa  in 
water,  mashed  potato  with  beef  juice  or  chicken  soup,  soft-boiled  egg, 
ground  rice  custards  and  similar  semisolid  articles  of  food.  In  a  great 
many  instances  "malt  soup,"  prepared  in  accordance  with  the  directions 
of  Keller,  acts  admirably,  both  as  a  tissue  builder  and  to  check  the  pro- 
tracted diarrhea.  Last  in  line,  but  foremost  in  importance,  is  the  fact 
that  in  young  infants  a  complete  cure  of  chronic  gastroenteritis  in  bot- 
tle-fed infants  is  effected  by  a  prompt  change  from  bottle  to  breast  feed- 
ing. 

The  medicinal  treatment  of  chronic  gastroenteritis  is  chiefly  symp- 
tomatic. When  vomiting  persists,  lavage  (with  warm  boric  acid  solu- 
tions) should  be  practiced  daily  or  every  alternate  day,  and,  if  need 
be,  continued  for  a  few  weeks.  Digestion  may  be  aided  by  means  of 
pancreatin  and  diastase,  and  the  appetite  improved  by  small  doses  of 
tincture  nux  vomica  and  dilute  hydrochloric  acid  and  pepsin.  The 
patient  should  be  given  daily  a  low  intestinal  irrigation,  either  with 
one  quart  of  plain  hot  (110°  F.)  water,  2  per  cent  of  bicarbonate  of 
soda,  or,  where  the  lesion  is  localized  principally  in  the  lower  bowel — 
as  indicated  by  predominance  of  blood  and  mucus  in  the  evacuations — 
with  1/10  per  cent  solution  of  nitrate  of  silver.  Where  the  diarrhea 
persists  notwithstanding  progressive  improvement  in  the  general  con- 
dition of  the  patient,  the  newer  tannin  preparations  {e.g.,  tannalbin, 
tannigen)  are  very  serviceable.  The  tannates  may  be  combined  with 
some  bismuth  preparation (e.  gf.,  subgallate  of  bismuth,  2  to  4  grains),  to 
enhance  the  astringent  effects,  and  small  doses  of  Dover's  powder  (i/4 
grain  every  three  hours)  to  arrest  active  peristalsis. 

Change  of  air  (seashore),  strict  cleanliness  of  the  body,  change  of 
position  and  frequent  picking  up  of  the  patient  from  its  bed,  and  ac- 
tive stimulation  (strychnine,  cinchona,  Tokay  wine  and  champaign)  are 
active  preventives  of  serious  complications. 


DISEASES   OF    THE    ALIMENTARY    TRACT  257 

Dysentery,  Enterocolitis,  Ileocolitis,  (See  page  412) 

Acidosis  (See  p.  522.) 

Proctitis 

Inflammation  of  the  roetnm  is  usually  secondary  in  character  and  not 
rarely  associated  Avith  gastroenterocolitis,  dysentery,  oxyurides,  and 
prolapsus  recti,  and  less  frequently  with  gonorrhea  (vulvovaginitis, 
{q.  V.)  and  diphtheria.  Occasionally  it  is  the  result  of  trauma  (e.  g.,  for- 
eign body),  and  the  effect  of  drastic  cathartics. 

The  principal  SA'mptoms  of  this  affection  consist  of  tenesmus  (some- 
times also  strangury),  frequent  discharge  of  blood,  mucus,  and  pus, 
with  little  fecal  matter,  and  more  or  less  severe  colic.  Depending  upon 
the  primary  cause  of  the  disease,  the  discharges  may  contain  different 
kinds  of  bacteria  {e.g.,  ameba,  gonococcus,  diphtheria  bacillus;  worms, 
etc.),  a  fact  which  should  always  be  borne  in  mind  before  arriving 
at  a  diagnosis  and  resorting  to  treatment.  Proctitis  should  not  be  con- 
founded with  rectal  fistula,  polypus  or  hemorrhoids,  purpura  hemor- 
rhagica and  intussusception.  The  treatment  depends  upon  the  underly- 
ing cause;  in  the  main  resembling  that  of  dysentery   (q.v.). 

Colica  Infantum,  Gastralgia,  Enteralgia,  Neuralgia  Enterica 

Infantile  colic  is  usually  associated  with  a  number  of  congenital 
(gastrointestinal  stenosis,  etc.)  and  acquired  (gastrointestinal  inflam- 
mations, etc.)  diseases  of  the  alimentary  tract.  Less  frequently  it  is 
apparently  free  from  organic  underlying  causes.  This  so-called  "idio- 
pathic" form  of  colic  is  a  spasmodic  affection  of  the  intestinal  muscula- 
ture, the  result  of  pathologic  irritations  which  act  by  way  of  the  periph- 
eral cutaneous  nerves  or  the  sensory  intestinal  nerves.  To  avoid 
unnecessary  repetition,  it  may  briefly  be  stated  that  anything  capable  of 
producing  gastrointestinal  disturbance  may  form  the  cause  also  of  the 
said  pathologic  irritations.  This  occurs  especially  in  premature  in- 
fants and  in  those  whose  digestive  organs  are  not  quite  fully  developed. 

Some  babies,  breast  or  bottle  fed,  begin  to  suffer  from  colic  soon 
after  birth,  and  do  what  you  will,  maintain  their  "record"  for  several 
months, — until,  with  gradual  growth,  the  digestive  organs  attain  their 
normal  functions.  Such  "colic-babies,"  if  reared  without  immediate 
strict  supervision  of  a  capable  nurse  or  physician  are  apt  very  soon  to 
contract  a  severe  gastrointestinal  disorder  from  the  effect  of  the  ex- 
perimental efforts,  in  feeding  and  medication,  on  the  part  of  all  Avho 
sympathize  with  the  "innocent  babe."  This  habitual  colic,  which  is 
manifested  by  continued  fretfulness,  sleeplessness,  and  pseudobulimia 


258  DISEASES   OF   CHILDREN 

(instinctive,  eager  desire  for  warm  drinks  which  temporarily  relieve  the 
pain),  is  to  be  distinguished  from  acute  intestinal  colic  (colica  flatulenta), 
which  is  sudden  in  development  and  rapid  in  disappearance,  the  latter 
depending  npon  the  time  required  to  get  rid  of  the  gas  or  stool.  During 
a  severe  attack  of  acute  colic  the  child's  face  is  spasmodically  drawn  and 
bathed  in  perspiration.  The  patient  refuses  food,  cries  pitifully,  and 
draws  its  legs  upon  the  abdomen.  The  spasm  sometimes  extends  to  the 
other  muscles  of  the  body,  leading  to  general  convulsions,  and  excep- 
tionally even  to  coma  and  fatal  issue.  Of  course,  in  the  majority  of  in- 
stances, the  termination  is  favorable,  especially  under  prompt  and  ap- 
propriate treatment. 

Treatment. — In  breast-fed  infants  attention  to  the  health  of  the 
mother  or  wet-nurse — avoidance  of  excitement,  regulation  of  the  bow- 
els, indulgence  in  outdoor  exercise — and  in  both  breast  and  artificially 
fed,  prevention  of  constipation  and  overfeeding  of  the  infant,  more 
particularly  with  fat  mixtures,  are  very  efficient  anticolic  measures. 
Where  repeated  examination  of  the  breast  milk  proves  it  to  be  too 
rich  in  fat  or  protein,  the  infant  should  be  given  a  few  teaspoonfuls 
of  water  or  of  some  other  diluent  immediately  before  each  nursing, 
and  the  length  of  time  for  each  nursing  proportionately  reduced. 

As  long  as  the  infant  thrives,  notwithstanding  the  colic,  no  very 
material  changes  in  the  feeding  should  be  attempted,  as  too  much 
experimenting  often  makes  matters  worse. 

In  habitual  as  w^ell  as  flatulent  colic,  heat,  either  in  the  form  of 
fomentations  (a  few  drops  of  turpentine  in  a  quart  of  warm  water), 
gentle  massage  of  the  abdomen  with  warm  oil,  or  warm  drinks  such 
as  chamomile,  fennel  seed  or  peppermint  tea,  will  be  found  to  act  well. 
In  cases  of  acute  colic  this  must  be  preceded  by  a  warm  w-ater  enema 
to  aid  in  the  expulsion  of  the  gas  or  stool.  Of  drugs,  the  following  prep- 
arations are  worth  trying: 

Charcoal  and  magnesia,  of  each  1  or  2  grains  one  hour  after  feeding ; 
mistura  sodae  et  menthae,  N.  F.,  5  to  10  drops  every  ten  minutes  until 
relieved;  compound  spirits  of  ether,  sweet  spirits  of  nitre,  or  cam- 
phorated tincture  of  opium  in  doses  of  from  2  to  5  drops,  to  be  re- 
peated two  or  three  times.  In  purely  nervous  colic  asafetida  often 
acts  magically.  The  lac  asafetida  (i/^  dram  to  1  pint  of  warm  water) 
should  be  gently  administered  by  rectum.  The  ammoniated  tincture 
of  Valeria  (5  drops)  and  sodium  bromide  (2  grains)  are  often  equally 
efficient.    As  to  the  treatment  of  convulsions,  see  p.  670. 

Proper  food,  regular  bowel  movements,  and  fresh  air  are  efficient 
prophylactic  measures. 


DISEASES   OF    THE    ALIMENTARY    TRACT  259 

Infantile  colic  should  not  be  confounded  with  intestinal  intussus- 
ception, appendicitis,  and  biliary,  renal  (uric  acid  infarct!),  or  vesical 
calculi. 

Chronic  Constipation 

Judging  l)y  the  construction  of  the  infantile  intestines — their  great 
length,  the  thinness  and  feebleness  of  their  musculature,  etc. — nature 
seems  to  have  intended  that  infants  as  well  as  older  children  should  be 
more  or  less  constipated.  Indeed,  the  popular  belief  that  healthy 
children  are  usually  constipated,  is  often  corroborated  by  actual  ob- 
servation. Not  infrequently,  however,  obstinate  constipation  gives 
rise  to  a  number  of  disagreeable  symptoms  (flatulence,  anorexia,  head- 
ache, restlessness,  sometimes  convulsions ;  anemia,  toxemia,  a  tendency 
to  renal  irritation,  possibly  with  colicystitis ;  proctitis,  anal  fissure,  pro- 
lapse of  the  rectum,  hemorrhoids,  etc.)  requiring  active  treatment,  a 
task  often  difficult  to  cope  with  in  view  of  the  uncertainty  of  the 
etiologic  factor  of  the  underlying  disease. 

The  causes  of  habitual  constipation  are  very  numerous.  Aside  from 
the  cases  resulting  from  gross  abnormal  anatomic  relations  or  diseases, 
such  as  the  different  varieties  of  atresia  intestini,  recti,  or  ani;  tumors; 
congenital  dilatation  with  hypertrophy  of  the  colon;  hypertrophy  of 
the  valvulae  conniventes ;  hypertrophy  of  the  so-called  rectal  valve ;  in- 
flammatory adhesions;  congenital  displacements — which  will  not  be 
discussed  here — constipation  is  ordinarily  caused  by  faulty  diet,  atony 
of  the  bowels,  and  constitutional  disturbances. 

Faulty  diet  is  responsible  for  a  great  many  cases  of  constipation. 
This  etiologic  factor  is  frequently  potent  also  in  infants,  when  the 
woman's  milk  contains  too  much  or  too  little  of  one  or  more  of  the 
constituents  of  milk,  or  when  it  is  insufficient  in  quantity.  In  arti- 
ficially fed  infants  the  cause  of  the  constipation  will  probably  be  found 
in  the  excess  of  fat  consumed.  In  some  children  constipation  is  due, 
on  the  one  hand,  to  too  early  and  persistent  feeding  with  amylaceous 
food,  and,  on  the  other  hand,  to  the  consumption  of  food  that  does  not 
stimulate  peristalsis,  such  as  an  exclusive  diet  of  milk,  meat,  eggs, 
etc.,  and  no  fruit,  potatoes,  bread,  fresh  vegetables,  etc. 

Atony  of  the  intestines  may  be  primary,  congenital  in  nature,  or 
secondary  or  acquired.  The  former  variety  can  frequently  be  traced 
as  an  hereditary  taint  through  several  generations.  Sometimes  there 
is,  in  addition  to  the  muscular  insufficiency,  also  congenital  weakness 
of  the  innervation  of  the  intestines.  The  latter  condition  embraces  also 
the  form  of  atony  usually  associated  with  congenital  diseases  of  the  brain 
and  spinal  cord.     Secondary  or  acquired  intestinal  atony  is  generally 


260  DISEASES   OF    CHILDREN 

the  result  of  repeated  attacks  of  temporary  constipation,  gastrointes- 
tinal indigestion  with  fermentation,  enterospasm,  arrest  of  peristalsis 
due  to  reflex  irritation  of  the  inhibitory  nerves  of  the  intestines,  acute 
inflammatory  processes  of  the  intestinal  canal  with  consecutive  atro- 
phy of  the  intestinal  coats,  constriction  of  the  lumen  of  the  bowels  by 
temporary  displacements  .  (enteroptosis,  hernia,  etc.),  habitual  sup- 
pression of  defecation  or  attention  to  it  at  irregular  hours,  enemas 
with  large  quantities  of  fluids,  etc.  All  these  etiologic  factors  produce 
intestinal  atony  b}'  directly  or  indirectly  distending  the  lumen  of  the 
bowels  and  depriving  the  intestinal  musculature  of  its  resilience  and 
tonicity. 

In  different  chronic  diseases  associated  with  general  debility  {e.g., 
rachitis)  and  loss  of  flesh ;  in  diseases  of  the  nervous  system,  such  as  in- 
fantile paralysis,  myelitis,  meningitis,  etc.,  the  sluggishness  of  the  bowels 
forms  merely  a  symptom  of  the  principal  disease.  Habitual  constipa-. 
tion  is  often  met  with  in  diseases  of  the  heart,  profound  anemia,  etc., 
as  a  result  of  venous  stasis  of  the  abdominal  organs.  To  the  same  cause 
is  attributable  also  the  constipation  occurring  in  children  who,  through 
deformity  or  when  otherwise  afflicted,  are  incapacitated  to  enjoy  a  suffi- 
cient amount  of  bodily  exercise. 

The  treatment  of  obstinate  constipation  in  infancy  and  childhood  re- 
solves itself,  first,  in  arresting  the  causes  instrumental  in  the  production 
of  the  disease;  secondly,  in  the  removal  of  the  damage  done  during  the 
continuance  of  the  constipation — not  quite  as  easy  a  task  as  some  authors 
wish  us  to  believe.  Indeed,  numbers  of  cases  of  chronic  constipation 
are  never  cured,  no  matter  what  therapeutic  means  are  being  employed. 
Preventive  measures  are,  therefore,  to  be  recommended  early  and  carried 
out  with  precision. 

It  is  of  primary  importance  to  train  the  child  to  have  a  movement  reg- 
ularly every  day.  Proper  habits  are  often  easily  formed  if  the  child  is 
put  upon  the  chamber  or  chair  invariably  at  the  same  hour.  The  first 
few  days  it  may  equire  local  stimulation  to  defecation  {e.g.,  introduc- 
tion into  the  rectum  of  a  small  oiled  syringe  tip).  Similar  means  should 
be  employed  also  with  older  children ;  particularly,  with  school  children 
who  are  very  apt  to  suppress  Nature's  impulse  to  empty  the  bowels. 

Two  main  factors  are  instrumental  in  the  expulsion  of  the  rectal  con- 
tents: contraction  of  the  abdominal  muscles  and  the  diaphragm,  and 
separation  or  relaxation  of  the  gluteal  group  of  muscles.  If  the  seat 
of  the  commo'de  is  too  high  and  the  aperture  in  the  seat  too  wide,  no  sup- 
port is  given  to  the  tubera  iscl\ii,  the  gluteal  muscles  are  crowded  to- 
^gether  instead  of  separated,  and  the  descent  of  the  floor  of  the  perineum 
is  much  hindered.    This  impediment  to  defecation  may  be  obviated  by 


DISEASES    OF    THE    ALIMENTARY    TRACT  261 

substituting  a  low  seat  on  a  nursery  chair  or  toilet,  or  small  vessel 
for  the  high  one  previously  used.  The  child  is  thus  enabled  to  accom- 
plish this  act  in  a  squatting  posture,  which  is  most  favorable  to  thor- 
ough emptying  of  the  rectum. 

Correction  of  diet  is,  of  course,  very  valuable  for  the  prevention  of 
habitual  constipation,  but  does  not  always  remedy  the  trouble.  This  is 
particularly  true  of  cases  of  very  long  standing,  since  here  we  are 
dealing  with  secondary. atony  following  prolonged  distention  and  enfee- 
blement  of  the  intestines.  The  diet  should  vary,  of  course,  with  the 
age  of  the  patient  and  consistency  of  the  stools.  As  a  rule,  the  latter  are 
either  small,  hard  and  marble-like,  or  very  large,  acholic,  and  sausage 
shaped.  In  the  first  case,  the  dietary  should  be  improved  by  the  addi- 
tion of  fat  and  cereal  gruels,  such  as  groats  and  oatmeal.  In  the  second 
case,  good  results  are  often  obtained  by  reducing  the  cereals  and  fats 
and  by  substituting  malt  cereals.  In  older  children  a  moderate  supply 
of  cream,  malt  extract,  honey,  rye  bread,  bran,  raw  or  cooked  fruit,  and 
vegetables  may  remove  the  difficulty.  A  glass  of  cold  water  on  an  empty 
stomach,  and  at  night  before  retiring,  is  often  very  useful. 

Faithful  compliance  with  the  suggestions  just  made  very  often  yields 
favorable  results.  In  a  certain  percentage  of  cases,  however,  more  active 
measures  have  to  be  resorted  to  and  it  then  devolves  upon  the  physician 
to  select  such  therapeutic  means  as  will  not  effect  the  general  wellbe- 
ing  of  the  patient.  In  older  children,  this  indication  can  most  appro- 
priately be  met  by  the  simultaneous  employment  of  a  combination  of  the 
so-called  physicochemic  procedures,  consisting  of  massage,  oil  enemas  and 
hydrotherapy,  and  occasionally,  also  electricity.  This  treatment  is  more 
advantageously  carried  out  in  the  evening,  before  the  patient  goes  to 
sleep.  The  child  is  placed  on  a  hard  couch  or  mattress  with  head  and 
thorax  raised  and  legs  sharply  flexed  at  the  knee-joints  and  somewhat 
rotated  outward.  The  attendant  stands  on  the  left  side  of  the  patient. 
The  manipulations  are  begun  at  the  fossa  iliaca  sinistra,  where  the  sigmoid 
flexure  is  situated  and  is  frequently  found  to  be  a  halting  place  for 
hardened  feces.  With  the  tips  of  the  fingers  of  one  hand  (in  older  chil- 
dren both  hands  may  be  used,  one  hand  being  placed  upon  the  other), 
the  attendant  makes  gentle  circular  movements  along  this  portion  of  the 
colon  and  at  the  same  time  exerts  upon  it  considerable  pressure  downward 
toward  the  rectum.  Without  changing  these  movements  the  attendant 
slowly  ascends  as  far  as  the  splenic  flexure.  From  here  he  gradually 
returns  to  the  sigmoid.  He  now  begins  a  new  tour,  going  as  far  as  the 
hepatic  flexure,  and  after  gradually  returning  to  the  starting  point  he 
makes  his  final  trip,  reaching  the  cecum  and,  in  the  manner  just  outlined, 
returns  again  to  the  fossa  iliaca  sinistra.     These  manipulations  should 


262  DISEASES    OF    CHILDREN 

be  followed  by  rhythmical  vibratory  strokes  over  the  entire  abdomen,  in- 
terrnpted  by  a  few  pressure  movements  against  the  spinal  column  in 
the  epigastric  region.  The  treatment  should  last  from  six  to  twelve 
minutes. 

Instead  of  trying  the  massage,  oil  enemas,  and  hydrotherapy  sepa- 
rately, it  is  certainly  preferable  to  employ  these  three  procedures — the 
anticostive  triad — simultaneously,  since  they  do  not  interfere  with  one 
another,  but,  on  the  contrary,  supplement  one  another  in  their  beneficial 
effect.  Thus,  after  completing  the  massage,  the  little  patient  is  turned 
upon  his  left  side,  and  by  means  of  a  piston  syringe,  1/2  ounce  or  more  of 
warm  oil  is  gently  injected  into  the  rectum  and  allowed  to  remain  there. 
This  is  followed  by  the  application  around  the  abdomen  of  a  Priessnitz 
compress,  which  should  be  left  in  place  until  the  next  morning.  It  will 
almost  invariably  be  found  that  the  patient's  bowels  will  act  either 
during  or  soon  after  the  treatment,  or  at  any  rate,  not  later  than  the 
following  morning.  A  three  or  four  weeks'  course  of  treatment  will 
usually  suffice  to  establish  regularity  of  the  bowels,  provided  the  preven- 
tive measures  suggested  before  are  strictly  adhered  to.  In  some  very 
protracted  cases  of  constipation  these  procedures  may  be  supplemented 
by  the  application  of  the  galvanic  or  faradic  current.  One  electrode  is 
passed  successively  over  different  portions  of  the  abdominal  wall,  and  the 
other  electrode  is  placed  upon  any  other  part  of  the  body. 

Proctologists  frequently  advocate  divulsion  of  the  sphincter  ani  as  a 
sure  cure  of  habitual  constipation.  I  am  not  inclined  to  be  quite  as 
enthusiastic  over  it,  except  in  cases  of  constipation  due  to  rectal  disease, 
as,  for  example,  fissura  ani,  rectospasmus,  etc. 

Finally,  there  is  a  class  of  cases  of  chronic  constipation  which  resists 
all  forms  of  treatment  as  regards  a  permanent  cure,  but  may  be  con- 
siderably improved  by  alternately  resorting  to  the  therapeutic  measures 
already  enumerated  as  well  as  to  drugs.  In  the  selection  of  an  evacuant 
the  physician  must  be  guided  by  the  etiologic  factors  and  the  individual 
peculiarities  of  the  case  in  question.  The  indiscriminate  use  of  anti- 
spasmodics (belladonna)  as  well  as  the  ever-ready  ''soothing"  laxatives, 
is  to  be  strongly  deprecated.  Of  all  the  laxatives  in  use,  mineral  oil 
is  the  safest  and  most  efficient.  In  a  child  five  or  six  years  old,  we  begin 
with  a  tablespoonful  once  a  day  and,  as  regular  evacuation  is  established, 
we  gradually  reduce  the  dose.  Temporarily  effective  and  comparatively 
harmless  are  also  the  following  remedies:  Soap  and  glygerine  supposi- 
tories, medicated  cocoa  butter  suppositories  (with  aloin  and  belladonna 
in  spastic,  or  aloin  and  nux  vomica  in  atonic,  constipation),  enemas  with 
small  quantities  of  glycerine  or  larger  quantities  of  soap  water;  inter- 
nally, magnesia  usta,  magnesia  and  rhubarb,  compound  licorice  powder. 


DISEASES   OF    THE    ALIMENTARY    TRACT 


263 


castor  oil,  extract  of  easeara  sagrada,  calomel  followed  by  a  mild  saline 
aperient,  and,  in  older  children,  the  standard  mineral  salts  or  waters. 

Whatever  the  method  of  treatment  employed,  the  establishment  of  a 
halit  to  move  the  bowels  regularly  at  a  certain  time  of  the  day  should 
at  all  times  be  our  chief  aim. 

Prolapsus  Ani,  Prolapsus  Recti 

If  the  prolapse  is  limited  to  the  mucous  membrane  of  the  anus,  the 
condition  is  spoken  of  as  prolapsus  ani;  if  the  lower  portion  of  the 


Fig.   60. — Prolapsus  recti. 

rectum  protrudes  through  the  anal  orifice,  it  is  known  as  prolapsus 
recti.  In  prolapsus  recti  the  protruding  part  comes  down  during  def- 
ecation in  the  form  of  a  round,  or  sausage-shaped,  glistening,  red 
or  bluish  red,  frequently  bleeding  mass.  In  the  beginning,  the  mucous 
membrane  slips  back  in  its  place  spontaneously,  or  is  easily  replace- 
able and  remains  there  until  the  next  movement ;  in  severe  cases,  owing 


264  DISEASES    OF    CHILDREN 

to  marked  inflammatory  thickening,  reposition  of  the  mass  may  be 
difficult,  and  if  replaced,  may  immediatelj^  prolapse  again. 

These  conditions  are  very  common  in  young  children,  the  softness 
of  the  connective  tissue  and  incomplete  development  of  the  muscular 
system  serving  as  predisposing  causes.  The  ordinary  exciting  causes 
are  habitual  constipation,  protracted  diarrhea,  proctitis,  rectal  poly- 
pus, oxyuris,  phimosis,  vesical  calculus,  i.  e.,  conditions  in  which  the 
act  of  defecation  or  urination  is  attended  by  pressing,  tenesmus,  or  stran- 
gury. Protracted,  paroxysmal  coughing  {e.g.,  pertussis),  by  its  down- 
ward pressure  upon  the  abdominal  contents,  also  serves  as  an  etiologic 
factor,  and  prolapsus  recti  is  not  infrequently  associated  with  rachitis, 
probably  due  to  the  accompanying  muscular  debility  and  constipation. 

The  diagnosis  can  readily  be  made  by  inspection  and  digital  examina- 
tion. It  is  most  apt  to  be  confounded  with  hemorrhoids  and  rectal  poly- 
pus. Rectal  polypus  is  the  most  frequent  cause  of  rectal  bleeding  in 
children,  and  appears  at  the  anus  as  a  dark-red,  bean-  to  cherry-sized, 
roundish  tumor  with  a  bleeding  surface.  Digital  examination  usually 
reveals  that  the  polyp  is  attached  to  the  rectum,  a  few  centimeters  above 
the  sphincter,  by  means  of  a  short  or  long  pedicle. 

Slight  prolapse  is  readily  amenable  to  reposition  of  the  prolapsed 
mass  (oiling  and  gentle  pressure  upward  with  the  patient  in  the  knee- 
chest  position)  and  strapping  of  the  buttocks  (in  older  children  only 
before  the  act  of  defecation),  in  addition  to  prompt  attention  to  the 
aforementioned  etiologic  factors.  Severer  cases  call  also  for  reduction 
of  the  local  inflammation  by  occasional  painting  of  the  affected  area 
with  balsam  of  Peru  or  a  2  to  5  per  cent  solution  of  nitrate  of  silver. 
If  these  measures  fail,  the  prolapsed  mass  may  have  to  be  treated  by 
punctate  or  linear  cauterization.  However,  the  possibility  of  subsequent 
anal  stricture,  should  be  kept  in  mind. 

General  tonic  treatment  not  rarely  succeeds  when  local  procedures  fail. 

Intussusception 

(Intestinal  Invagination) 

Intussusception,  or  sliding  of  one  portion  of  the  intestines  into  the 
other,  is  an  affection  principally  of  infancy  and  early  childhood.  The 
commonest  seat  of  the  trouble  is  the  ileocecal  region.  Thus,  the  proxi- 
mal portion  of  the  ileum  with  or  without  the  cecum  becomes  invagi- 
nated  into  the  colon.  Less  frequently  the  ileum  slides  into  the  ileum, 
or  a  part  of  the  colon  into  the  colon.  Occasionally  the  invagination  is 
multiple  and  is  responsible  for  the  so-called  recurrent  intussusception  (A. 
Sturmdorf).     The  immediate  results  of  the  invagination  are  agglutina- 


DISEASES    OP    THE    ALIMENTARY    TRACT  265 

tion  of  the  opposed  serous  layers  and  strangulation  of  the  impacted 
portion  of  the  intestine.  If  the  latter  is  not  soon  relieved,  gangrene, 
sloughing  and,  in  a  few  days,  spontaneous  discharge  of  the  cast-off 
piece  of  intestine  occurs — the  continuity  of  the  intestine  being  preserved 
by  end-to-end  adhesion. 

The  disease  sets  in  very  suddenly.  In  the  midst  of  apparently  perfect 
health,  or  preceded  by  diarrhea  and  colic,  the  child  suddenly  shrieks 
from  intense  pain  and  presents  other  symptoms  of  severe  colic  which 
fail  to  yield  to  ordinary  anticolic  therapeutic  measures.  The  pain  and 
restlessness  increase,  the  abdomen,  which  at  first  may  be  normal  or  even 
retracted,  soon  becomes  greatly  distended,  and,  accompanied  by  marked 
tenesmus,  the  child  passes  from  the  bowels  at  first  small  quantities  of 
feces  mixed  with  mucus  and  blood,  and  later  pure  blood,  often  of  a  cadav- 
eric odor. 

Digital  examination  discloses  blood  in  the  rectum — often  long  before 
any  is  passed  with  the  stools — and  if  the  intussusception  is  colonic  in 
form,  frequently  a  round  mass  is  observed  high  up  in  the  rectum.  Ex- 
ceptionally and  late  the  tumor  protrudes  from  the  anus.  In  ileocecal  in- 
tussusception, inspection  and  palpation  reveal  a  round  ''lump"  or  sau- 
sage-shaped mass  in  the  right  iliac  region,  and  occasionally  a  depression 
below  the  tumor — owing  to  displacement  of  the  cecum.  The  tumor  is 
less  pronounced  in  intussusception  of  other  portions  of  the  intestines, 
and  in  some  cases  can  only  be  detected  under  anesthesia. 

The  severity  of  the  onset  is  no  criterion  as  to  the  further  course  of  the 
disease.  In  a  small  number  of  cases  the  colic  suddenly  ceases,  the  child 
resumes  its  normal  appearance,  and  exhausted  from  the  agonizing  pain, 
falls  into  a  profound  sleep,  waking  up  apparently  well — spontaneous 
improvement  or  recovery  by  spontaneous  reduction  of  the  invagina- 
tion has  apparently  occurred.  In  such  a  cure  the  trouble  is  not  al- 
ways at  an  end,  for  the  intussusception  is  very  apt  to  return  after 
a  shorter  or  longer  interval.  In  another  group  of  cases,  after  the 
grave  onset,  the  disease  may  pursue  a  milder  course.  The  vomiting, 
meteorism,  and  tenesmus  abate  in  their  violence;  the  dejecta  lose  their 
bloody  consistency,  and  the  colicky  pain  returns  only  after  long 
pauses.  After  three  to  six  days,  a  piece  of  gangrenous  intestine,  the  in- 
tussuscepted  portion,  may  be  discharged  per  rectum.  This  process  is 
always  fraught  with  danger,  the  greater  number  of  these  patients 
dying  from  general  sepsis.  The  few  patients  who  survive  frequently 
succumb  to  consecutive  chronic  gastrointestinal  catarrh,  with  or  with- 
out intestinal  stricture.  In  the  majority  of  instances,  the  symptoms 
grow  worse  within  twenty-four  hours  from  the  start  of  the  attack. 
The  vomiting  becomes  violent  and  stercoraceous,  the  pulse  feeble,  the 


266  DISEASES   OF   CHILDREN 

extremities  cold,  the  expression  of  the  face  pinched,  the  eyes  sunken, 
and,  unless  the  condition  is  promptly  relieved,  the  child  succumbs 
within  from  four  to  eight  days  to  increasing  collapse,  not  rarely  pre- 
ceded by  intestinal  perforation  and  jieritonitis. 


Fig.  61. — Stick  pin  in  transverse  colon  giving  rise  to  symptoms  of  intussusception 

requiring  operation. 

At  all  events  the  prognosis  is  very  grave.  The  mortality  ranges 
between  from  50  per  cent  and  80  per  cent  in  cases  left  alone  or  treated 
palliatively.  On  the  other  hand,  with  prompt  surgical  treatment,  the 
chances  for  recovery  are  by  far  better— about  65  per  cent.    The  best 


DISEASES   OF    THE   ALIMENTARY    TRACT 


267 


results  (75  per  cent)  are  obtained  in  cases  operated  upon  within  twen- 
ty-four hours  of  the  onset  of  the  attack. 

The  treatment  of  choice,  therefore,  is  obvious.  Early  operative  in- 
terference,— before  extensive  adhesions  and  gangrene  of  the  bowels 
have  taken  place.  Temporizing  is  fatal.  However,  before  an  opera- 
tion is  resorted  to,  we  must  be  quite  certain  that  we  are  not  dealing 
with  acute  peritonitis,  appendicitis  or  intestinal  obstruction  from 
other  causes — with  which  diseases  intussusception  is  most  apt  to  be 
confounded. 

Differential  Diagnosis 


CHARACTERIS- 

INTUSSUSCEP- 

ACUTE AP- 

ACUTE PERI- 

STRANGULA- 

TIC   SYMPTOMS 

TION 

PENDICITIS 

TONITIS 

TION 

Onset    

Sudden 

Variable 

Variable 

Sudden 

Tumefaction, 

Most  frequently 

McBurney  's 

Distributed 

Local       disten- 

its scat  and 

ileocecal     re- 

point.       Eig- 

throughout 

tion  of  bowel. 

nature    

gion,  occa- 

idity   of    ab- 

abdomen,   al- 

Chiefly at  ab- 

sionally 

dominal  v^all 

so   local   exu- 

dominal 

round    tumor 

dation 

rings 

in  rectum 

Tympanites  . . . 

Moderate 

Absent,  at  first 

Pronounced 

Slight 

Abdominal 

pain    

Intense,  general 

Moderate,  local 

Marked,  gen- 
eral 

Severe,  gen- 
eral 

Constipation    .  . 

Late,  preceded 
by  frequent 
mueo- 

hemorrhagic 
stools 

Early 

Late 

Early 

Fever   

Slight 

High 

High 

Slight 

Collapse   

Early 

Late 

Early 

Early 

When  the  services  of  a  competent  surgeon  are  not  obtainable,  an 
attempt  may  be  made  to  reduce  the  invagination  by  copious  injections 
of  warm  (100°  F.)  water  into  the  bowels,  or  by  air  inflation. 

For  the  water  injections  an  ordinary  fountain  syringe  with  a  rectal 
tube,  suspended  about  4  feet  above  the  level  of  the  patient's  pelvis, 
answers  the  purpose.  Two  to  4  quarts  of  water  should  be  used.  Dur- 
ing this  procedure  the  patient  should  be  kept  on  his  back  with  his 
buttocks  raised  about  1  foot  above  the  level  of  the  shoulders.  Occa- 
sional inversion  of  the  child,  or  the  Trendelenburg  position  under  anes- 
thesia is  useful. 

For  the  relief  of  pain  and  arrest  of  undue  peristalsis,  morphine  and 
atropine  hypodermically ;  to  check  vomiting,  lavage;  to  combat  col- 


268  .  DISEASES    OF    CHILDREN 

lapse,  stimulants  and  external  heat.  Liquid  food  that  is  easily  di- 
gestible should  be  given  to  sustain  nutrition.  Complications  arising, 
should  be  treated  according  to  indications. 

In  view  of  the  obscure  causes  of  this  affection,  very  little  can  be 
accomplished  in  the  way  of  prophylaxis.  Avoidance  of  habitual  con- 
stipation, of  drastic  purgatives,  and  of  violent  exercise  (rapid  up-and- 
down  motion)  may  prove  efficient  prophylactic  measures.  Occasion- 
ally, intussusception  follows  typhoid  fever,  Meckel's  diverticulum  and 
severe  adhesions  secondary  to  appendectomy.  The  relationship  be- 
tween invagination  and  polypoid  intestinal  growths  still  lacks  authori- 
tative confirmation. 

Case  Report. — As  is  usual  in  acute  intussusception,  the  five-months-old  infant  un- 
der my  observation  was  suddenly  seized  with  pain  and  vomiting,  became  very 
restless  and  refused  to  take  the  breast  on  which  she  had  been  nursed  from  birth 
on.  As  the  mother  of  the  baby  had  at  the  time  been  greatly  worried  over  the  fate 
of  her  husband,  who  was  undergoing  an  operation  for  strangulated  hernia,  she 
attributed  the  unexpected  illness  of  her  child  to  some  "nervous"  disturbance  of 
her  breast  milk.  Moreover,  on  a  few  occasions  the  baby  had  also  received  a  bot- 
tle or  two  of  diluted  cows'  milk,  which  she  thought  might  have  upset  her  stomach. 
In  addition  to  this  the  baby  three  days  before  rolled  out  of  its  go-cart,  head  down- 
wards, although  apparently  without  any  noticeable  bad  after-effects.  A  physician 
Avas  sent  for  the  same  day,  and  finding  the  baby  suffering  from  colic,  diarrhea  and 
vomiting,  ordered  a  teaspoonful  of  castor  oil,  and  a  rectal  irrigation,  to  be  fol- 
lowed a  few  hours '  later  by  small  doses  of  salol  and  bismuth.  The  next  day  the 
stools  assumed  a  bloody  consistency,  and  presuming  that  dysentery  was  dealt  with, 
he  added  a  few  doses  of  Dover's  powder.  The  opium  seemed  to  relieve  the  colie, 
but  the  bloody  stools  continued.  Alarmed  over  this  condition  the  family  physician 
kindly  invited  me  to  see  the  case  with  him.  This  was  about  three  days  after  the 
onset  of  the  vomiting.  The  patient  was  drowsy,  and  its  facial  features  were 
greatly  depressed.  Her  temperature  was  100°  F.,  the  pulse  slow  and  feeble,  and 
she  seemed  entirely  free  from  pain.  Her  abdomen  was  slightly  distended  but  on 
palpation  I  readily  detected  an  oval-shaped  doughy  mass  in  the  left  iliac  region 
which  was  very  sensitive  to  pressure.  Furthermore,  on  introducing  the  finger  into 
the  rectum,  about  two  ounces  of  bloody  fluid  was  forcibly  expelled  from  the  rec- 
tum along  the  sides  of  the  examining  finger.  There  could  be  no  doubt  as  to  the 
diagnosis.  The  sudden  onset,  the  persistent  vomiting  (which  by  the  way  was  not 
feculent ! ) ,  the  bloody  discharge  free  from  feces,  the  intense  colic  and  above  all, 
the  painful  mass  in  the  left  iliac  region,  were  pathognomonic  of  intussusception. 
Dysentery  was  a  plausible  diagnosis  the  first  day,  but  surely  not  thereafter,  when 
free  blood  made  its  appearance.  In  some  cases  intussusception  may  be  mistaken 
for  incipient  appendicitis,  impaction,  peritonitis  or  strangulation,  but  in  none  of 
these  cases  would  we  find  serosanguinolent  and  later  purely  bloody  stools.  Besides, 
these  diseases  have  pathognomonic  symptoms  of  their  own,  which  must  always  be 
considered  in  the  differential  diagnosis.  I  suggested  an  immediate  operation,  and 
Dr.  Lilienthal  performed  the  same  within  an  hour.  The  laparotomy  revealed  a 
colonic  invagination  at  the  sigmoid  flexure,  embracing  the  entire  colon  including  the 
cecum.     The  baby  succumbed  a  few  hours  later. 


DISEASES    OF    THE    ALIMENTARY    TRACT  260 

Appendicitis,  Typhlitis,  Perityphlitis 

Until  recently  the  prevalence  of  appendicitis  in  early  childhood  was 
not  taken  very  seriously  by  the  profession  at  largo,  and  hence,  either 
because  of  its  skepticism,  or  for  want  of  understanding  of  the  pathol- 
ogy of  the  disease,  a  great  many  cases  of  acute  or  chronic  appendicitis 
were  either  overlooked,  erroneously  diagnosed  or  ascribed  to  ''food 
fever,"  "cyclic  vomiting,"  and  the  like.  Nowadays,  the  occurrence 
of  appendicitis  in  children  and  even  in  sucklings  is  no  longer  doubted. 
On  the  contrarj',  in  view  of  the  frequency  with  which  the  vermiform 
process  is  found  implicated  in  the  course  of  severe  infantile  gastroin- 
testinal disease,  and  its  tendency  by  its  relatively  greater  length  and 
width  to  favor  lodgment  of  foreign  bodies  (such  as  fecal  concretions, 
worms,  etc.,  which  act  as  sources  of  infection),  there  is  ample  reason 
for  the  belief  that  as  a  wdiole  appendicitis  is  as  common  in  children 
as  in  adults.  As  in  the  latter  the  severity  of  the  disease  in  infants  varies 
from  simple  inflammation  to  fatal  gangrene,  depending  of  course  upon 
the  type  and  virulence  of  the  causative  bacteria  and  the  promptness 
with  which  it  is  discovered  and  treated. 

Pathologically  the  simplest  form  of  appendicitis  consists  of  a  catar- 
rhal inflammation  of  the  appendix.  Its  mucosa,  and  follicles  are  red- 
dened and  swollen,  and  their  secretion  is  more  abundant  than  normal. 
The  lymphatics  of  the  walls  and  of  the  surrounding  structures  are 
congested.  Gradually  the  submucous  and  serous  layers  become  in- 
volved and  the  appendicular  lumen  narrow'ed.  In  mild  cases  the  ob- 
struction in  the  appendix  subsides,  allowing  the  escape  of  the  mucous 
and  bacterial  contents,  and,  with  the  exception  of  slight  thickening 
and  adhesions,  rapid  restitutio  ad  integrum  takes  place. 

In  more  severe  cases  the  obstruction  continues,  the  appendix  becomes 
more  and  more  distended,  the  mucous  secretion  purulent,  the  muscular 
coat,  owing  to  its  effort  to  expel  the  appendicular  contents,  thicker, 
hypertrophied,  while  the  mucous  membrane,  as  a  result  of  pressure  from 
within  the  appendix,  undergoes  gradual  atrophy  and  ulceration.  Even 
in  this  stage  of  the  disease  spontaneous  recovery  by  encapsulation  and 
absorption  of  the  abscess  is  still  possible. 

In  the  majority  of  instances,  however,  instead  of  being  absorbed,  the 
purulent  content  of  the  appendix  gradually,  or  rapidly,  increases  in 
quantity,  and  finally  perforates  the  overdistended,  more  or  less  ulcerated 
appendix.  The  escaping  pus  finds  its  way  where  there  is  least  resistance 
— into  the  cecum,  small  intestine,  rectum,  urinary  bladder,  gall  bladder, 
diaphragm  or  into  the  free  peritoneal  cavity.  The  pus  may,  on  rare 
occasions,  also  penetrate  into  the  retroperitoneal  cavity,  or  externally, 
usually  in  the  right  iliac  region. 


270  DISEASES    OF    CHILDREN 

Sometimes  the  inflammation  is  almost  from  the  start  so  intense  that 
perforation  and  gangrene  of  the  appendix,  and  escape  of  its  virulent 
contents  into  the  peritoneal  cavity  occur  before  a  diagnosis  can  at  all 
be  arrived  at.  In  these  cases  it  is  not  rare  to  find  also  old  inflammatory 
adhesions,  indicating  that  the  patient  had  once  before  gone  through  an 
attack  of  appendicitis  (recurrent  appendicitis),  which  probably  was 
mild  and  had  escaped  attention. 

The  great  variability  in  the  course  and  termination  of  the  aforemen- 
tioned pathologic  process  can  readily  be  explained  primarily  by  the  dif- 
ference in  the  virulence  of  the  causal  bacteria,  no  single  type  of  which 
having  thus  far  proved  to  be  the  specific  etiologic  factor  of  appendicitis 
as  a  whole  or  of  any  of  its  forms.  The  bacteria  found  in  the  inflam- 
matory products  of  the  disease  are  principally  streptococci,  staphy- 
lococci, B.  coli  communis,  the  pneumococcus,  B.  influenza,  etc.  It  is 
not  at  all  uncommon  for  appendicitis  to  develop  in  connection  with 
pneumonia,  influenza,  gastrcenterocolitis,  etc.,  thus  tending  to  prove 
its  infectious  character.  Prominent  etiologic  factors  also  are  retention 
of  fecal  concretions,  foreign  bodies  (pins,  fish  bones,  cherry  stones, 
orange  pits),  intestinal  worms,  traumatism,  exposure  to  cold  and  wet, 
etc.  In  a  baby  eighteen  months  old,  who  was  operated  upon  for  in- 
guinal hernia,  we  found  seven  pinworms  and  two  carawa'y  seeds  in  a 
perfectly  normal  appendix.  Male  children  (possibly  because  more  often 
exposed  to  traumatism)  are  more  frequently  attacked  by  appendicitis 
than  female  children.  Constipation  and  dyspepsia  serve  as  predispos- 
ing causes. 

Acute  appendicitis  may  set  in  very  suddenly  or  be  preceded  by  pre- 
monitory signs,  consisting  of  frequently  recurring  attacks  of  dyspepsia, 
with  colic  and  constipation.  It  is  quite  probable,  however,  that  the  dys- 
peptic symptoms  are  in  reality  the  manifestations  of  recurrent  catarrhal 
appendicitis  of  very  mild  type.  The  appendicitis  once  established,  the 
little  patient  stops  eating,  is  nauseated,  vomits,  and  cries  because  of 
pain  in  the  abdomen.  The  latter  is  more  or  less  rigid.  The  anorexia 
is  usually  complete,  and,  if  the  child  is  forced  to  eat,  the  food  is  sooner 
or  later  ejected.  Infants  may  continue  taking  the  bottle  or  breast,  to 
quench  thirst.  In  very  mild  cases,  nausea  may  replace  the  vomiting, 
but  the  latter  symptom  is  always  present  in  moderately  severe  cases 
and  is  quite  severe  in  grave  appendicular  involvement,  especially  when 
the  peritoneum  is  implicated.  Pain,  spontaneous  and  on  pressure,  is 
invariably  present  during  an  attack,  but  it  varies  greatly  in  severity 
irrespective  of  the  pathologic  condition  of  the  appendix.  Sudden  ces- 
sation of  pain  often  signifies  mortification  of  the  underlying  structures, 
and,  hence,  is  to  be  looked  upon  as  a  bad  omen.    Young  children  are  usu- 


DISEASES   OF    THE    ALIMENTARY    TRACT  271 

ally  unable  to  localize  the  seat  of  the  pain  they  are  suffering  from ; 
little  reliance,  therefore,  should  be  placed  upon  its  localization.  On 
the  other  hand,  pressure  pain  can  readily  be  elicited,  which,  as  a  rule, 
is  most  intense  over  the  region  of  the  appendix,  and  which  in  children 
does  not  always  correspond  with  "McBurney's  point" — the  appendix 
is  often  situated  either  higher  up  or  lower  down  in  the  pelvis.  Some- 
times, even  infants  indicate  the  presence  of  pressure  pain  by  attempt- 
ing unconsciousl}''  to  ward  off  the  examining  hand,  by  placing  their 
little  hands  over  the  most  painful  spot.  Rigidity  of  the  abdominal  wall 
forms  a  pathognomonic  sign  of  the  disease,  and  proves  of  great  help 
in  the  diagnosis  of  appendicitis  to  one  familiar  with  the  peculiar  sense 
of  resistance  of  the  abdominal  wall  to  pressure.  As  a  rule,  the  abdomen 
is  distended,  but  it  may  also  be  contracted  and  as  hard  as  a  board.  On 
gentle  palpation  the  rigidity  yields  sufficiently  to  permit  the  detection 
of  tumefaction — the  underlying  thickened  appendix  in  catarrhal  ap- 
pendicitis, or  the  variously  sized,  hard  or  doughy,  immovable  mass  in 
appendicular  abscess.  In  rare  cases  the  tumefaction  may  be  seen  to 
project  beyond  the  normal  level  of  the  skin,  or  be  felt  in  the  rectum ; 
a  digital  examination,  therefore,  should  never  be  omitted.  As  a  rule,  the 
patient  suffers  pain  when  his  right  leg  is  extended  forcibly,  and  in 
walking  he  usually  "favors"  this  leg  and  often  puts  the  right  hand  upon 
the  abdomen  to  prevent  shaking  of  the  underlying  structures.  Appendi- 
citis is  ordinarily  associated  with  complete  constipation ;  the  attack  may, 
however,  be  ushered  in  by  diarrhea,  or,  rather,  pseudodiarrhea,  since  the 
stool  is  derived  chiefly  from  the  lower  part  of  the  colon,  superinduced 
by  the  sudden  irritation  within  and  about  the  appendix.  As  the  dis- 
ease advances,  in  consequence  of  pressure  by  the  growing  tumefaction  in 
the  pelvis,  there  may  be  severe  tenesmus  (as  well  as  strangury)  with  or 
without  a  bloody  discharge, — a  symptom  which  is  very  apt  to  mask  the 
diagnosis.  The  temperature  is  moderate,  from  101°  F.  to  103°  F.  in 
catarrhal  appendicitis,  and  as  high  as  105°  F.  in  abscess  formation.  In 
favorable  cases  the  pulse  and  respiration  agree  with  the  rise  or  fall  of 
the  fever.  Low  temperature  with  a  high,  feeble  pulse  and  complete 
cessation  of  pain  are  considered  a  bad  omen,  an  indication  of  profound 
sepsis  or  perforation  of  abscess. 

Diagnosis. — Cases  presenting  the  aforementioned  typical  symptoms 
of  appendicitis  can  be  diagnosed  as  readih^  in  the  child  as  in  the  adult. 
In  fact,  owing  to  the  thinness  of  the  infantile  abdominal  wall,  and  the 
proportionately  large  size  of  the  appendix,  it  is  usually  not  difficult 
to  palpate  an  inflamed  appendix  unless  it  be — as  it  sometimes  hap- 
pens— misplaced  somewhere  beyond  the  reach  of  palpation.  On  the 
other  hand,  there  is  often  considerable  difficulty  to  differentiate  an 


272  DISEASES   OF   CHILDREN 

appendicitis  pursuing  a  very  violent  course  with  marked  tympanites, 
shock  and  collapse,  from  a  grave  attack  of  acute  g-astroenterocolitis, 
pneumonia,  typhoid  with  perforation,  intussusception,  pcrinephritie 
abscess,  hernial  strangulation,  severe  purpura  hemorrhagica  and  the  like. 
Even  in  such  eases  careful  analysis  of  the  typical  symptoms  of  the  re- 
spective diseases  rarely  fails  to  lead  to  a  correct  diagnosis.  Chronic  ap- 
pendicitis with  recurrent  acute  exacerbations  can  usually  be  differentiated 
from  renal  calculi  by  x-ray  examination  and  cystoscopy. 

Course  and  Termination. — The  severity  or  mildness  of  the  onset  of 
an  attack  of  appendicitis  bears  no  positive  relation  to  the  further 
course  of  the  disease.  After  the  inflammatory  process  has,  so  to  say, 
localized  itself,  which  occurs  usually  within  the  first  twenty-four  or 
forty-eight  hours,  the  physician  is  able  in  the  majority  of  instances  to 
conclude  what  sort  of  a  ease  he  is  dealing  with.  By  that  time  he  will 
find  that  in  catarrhal  appendicitis  the  vomiting  has  partially  or  en- 
tirely ceased,  the  pain  diminished,  the  abdominal  rigidity  lessened, 
and  the  tumefaction  become  less  palpable.  The  child  is  able  more  easily 
to  move  about  in  bed,  to  have  a  few  hours  of  comfortable  sleep,  oc- 
casionally to  expel  flatus,  and  to  express  a  desire  for  food.  Unevent- 
ful recovery  may  now  take  place  within  ten  days,  i.  e.,  as  far  as  sub- 
jective signs  are  concerned.  In  the  majority  of  cases  some  morbid  ana- 
tomic changes  remain  in  the  appendix  and  adjacent  structures,  e.  g.,  in- 
flammatory adhesions,  kinking,  constriction  of  the  lumen,  etc.  The  re- 
gion of  the  appendix  thus  remains  a  locus  minoris  resistenticB  for  life, 
subject  to  recurrent  attacks  of  inflammation  and  its  sequelae. 

Sometimes  after  an  apparently  benign  course  of  a  few  days'  duration, 
either  without  discernible  cause  or  as  a  result  of  gross  errors  in  diet, 
undue  exercise,  and  the  like,  there  is  a  sudden  change  for  the  worse. 
The  symptoms,  spoken  of  as  occurring  with  the  onset,  return,  some- 
times even  in  more  pronounced  form ;  the  patient  vomits,  has  chills, 
headache,  severe  pulling  and  throbbing  pain  in  the  abdomen.  The 
temperature  rises,  the  pulse  increases  in  frequency  and  tension,  res- 
piration is  quick  but  superficial  (the  patient  is  afraid  to  cough  or  take 
a  deep  breath  owing  to  the  increase  of  the  pain  with  the  descent  of  the 
diaphragm)  ;  the  child  is  restless  and  sleepless,  lies  principally  on  his 
back  with  his  right  leg  flexed  (attempt  to  extend  it  aggravates  the 
pain),  and  cries  with  pain  on  being  moved  about.  Palpation  reveals 
a  distinct  oblong  tumor,  the  distended  appendix,  which  is  very  ten- 
der, and  gives  rise  to  a  gurgling  sound  on  pressure.  This  physical  sign 
is  often  absent  in  the  so-called  retrocecal  appendical  abscesses!  If  the 
disease  is  not  checked  by  operation,  the  indurated  mass  enlarges,  loses 
its  circumscribed  character,  becomes  more  doughy  in  consistency,  and 


DISEASES   OF    THE    ALIMENTARY    TRACT  273 

dull  on  percussion ;  in  short,  it  presents  unmistakable  signs  of  a  fluid 
content — an  abscess.  This  clinical  picture  of  suppurative  appendicitis 
does  not  by  any  means  follow  only  the  catarrhal  variety ;  on  the  con- 
trary, quite  often  it  is  in  full  development  within  the  first  two  or  three 
days  of  the  disease,  and  if  the  abscess  is  not  promptly  opened,  it  bursts, 
often  giving  rise  to  general  peritonitis  and  quick  death.  More  rarely 
the  accumulation  of  pus  occurs  very  slowly  and  gradually,  and  even 
remains  in  abeyance  for  a  period  of  weeks  or  months,  during  which 
time  the  abscess  becomes  walled  off  from  the  general  peritoneal  cavity 
by  inflammatory  adhesions,  and  may  finally  be  absorbed,  or,  with  re- 
current attacks  of  appendicitis,  perforate  the  sac  and  wander  into  any 
of  the  neighboring  structures,  sooner  or  later  leading  to  the  grave 
symptoms  previously  spoken  of. 

In  another  group  of  cases — fulminating,  gangrenous  appendicitis — 
the  symptoms  are  extremely  alarming  immediately  from  the  begin- 
ning of  the  attack.  In  the  midst  of  apparent  good  health,  or  preceded 
by  slight  malaise,  vomiting,  colic,  prostration  and  collapse,  following 
one  another  in  rapid  succession,  and  often  without  palpable  local 
appendicular  tumefaction,  or  other  signs  pathognomonic  of  appendi- 
citis, the  typical  picture  of  general  septic  peritonitis  is  in  its  full  sway, 
— sometimes  within  twenty-four  hours  (usually  after  from  three  to 
five  days)  carrying  the  little  victim  to  the  grave.  In  such  cases  post- 
mortem examination  reveals  either  preexisting  infection  of  the  peri- 
toneum, or  sloughing  of  a  gangrenous  appendix,  involvement  of  ad- 
joining blood  vessels  (thrombophlebitis)  and  general  sepsis  (pyemia). 

Treatment. — In  view  of  the  uncertainty  of  the  course  of  the  disease, 
every  case  of  appendicitis  should  sooner  or  later  be  operated  upon. 
This  opinion  is  in  accord  with  that  held  by  the  best  modern  clinicians. 
The  profession  is  still  divided,  however,  on  the  question  of  the  time 
when  operative  procedures  prove  most  propitious  for  the  patient's 
uneventful  recovery.  In  solving  so  difficult  a  problem,  the  physician 
must  be  guided  (1)  by  the  condition  of  the  patient,  and  (2)  the  prog- 
ress of  the  disease. 

1.  The  Condition  of  the  Patient. — It  certainly  would  be  folly  to 
operate  on  a  child  in  a  moribund  condition,  or  on  one  synchronously 
suffering  from  a  systemic  fatal  disease  per  se,  e.  g.,  miliary  tuberculo- 
sis, diabetes,  grave  heart  or  kidney  disease,  and  the  like.  An  operation 
should,  if  feasible,  be  deferred  in  infants  under  six  months  of  age,  be- 
cause of  the  lack  of  resistance  of  the  patient,  and  in  view  of  the  fact 
that  in  very  young  infants  spontaneous  recovery  (at  least  temporary), 
by  absorption  of  the  pus,  or  rupture  of  the  abscess  in  the  rectum,  is 
by  no  means  rare. 


274         -  DISEASES   OF    CHILDREN 

2.  Progress  of  the  Attack. — Mild  catarrhal  appendicitis,  with  the 
first  attack,  progressing  favorably  during  the  first  four  days,  may  be 
left  alone  until  the  quiescent  stage,  when  the  appendix  should  be 
removed.  Severe  or  recurrent  catarrhal  appendicitis,  failing  to  im- 
prove after  the  fourth  or  fifth  day  or  showing  incipient  symptoms  of 
suppuration  (increased  leucocytosis),  should  be  operated  upon  at 
once;  or,  if  for  some  reason  an  operation  cannot  be  undertaken,  it 
should  be  treated  medically  for  a  week  or  ten  days  longer,  until  the 
abscess  has  become  circumscribed  and  encapsulated,  when  an  opera- 
tion should  be  performed  without  further  delay.  The  same  rule  ap- 
plies also  to  all  eases  of  slowly  developing  suppurative  appendicitis, 
the  physician  being  constantly  on  the  guard,  however,  for  sudden 
threatening  symptoms  of  perforation, — in  the  latter  event  demanding 
prompt  surgical  interference.  Finally,  an  immediate  operation  is  im- 
perative in  all  cases  of  perforative  and  gangrenous  appendicitis,  pro- 
crastination proving  almost  invariably  fatal. 

When  a  patient  is  seen  early,  it  is  advisable  to  administer  one  dose 
of  castor  oil  or  calomel  with  bicarbonate  of  soda,  to  wash  out  the 
stomach  (in  the  presence  of  vomiting)  and  intestines — to  clean  the 
alimentary  canal  of  its  contents.  This  should  be  followed  by  an  oc- 
casional administration,  in  the  form  of  suppositories,  of  very  small 
doses  of  codeine  or  opium,  to  arrest  peristalsis  and  to  keep  the  child 
perfectly  at  rest  and  free  from  severe  pain.  No  medication  by  mouth. 
During  the  acute  stage  of  the  disease,  the  constant  application  of  ice 
is  useful  to  relieve  pain  and  arrest  rapid  progress  of  the  inflammation. 
Thirst  should  be  relieved  by  small  quantities  of  water  or  tea ;  and  so  long 
as  anorexia  exists,  no  attempt  at  forced  feeding  should  be  tolerated.  An 
occasional  teaspoonful  of  milk  or  broth  will  prove  sufficient  to  sustain 
life  for  days.  Any  indiscretion  in  the  diet  is  hazardous.  I  have  fre- 
quently observed  recurrence  of  an  attack  after  partaking  of  cold  drinks 
or  ice  cream.  More  liberal  feeding  may  be  practiced  after  subsidence 
of  the  acute  symptoms,  after  repeated  escape  of  flatus  or  of  partly 
formed  stool.  Even  then  extreme  caution  is  commended,  limiting  the 
dietary  to  slowly  increasing  quantities  of  milk,  broths ;  albumin  water ; 
in  older  children,  fresh  soft-boiled  eggs,  milk  toast,  small  portions  of 
fine  cereals,  etc.  For  marked  tympanites,  atropine  and  morphine  hypo- 
dermically.  Stimulation  by  means  of  strychnine  and  normal  saline 
solution,  both  subcutaneously,  should  be  resorted  to  in  accordance  with 
indications.  As  the  patient  recovers,  medication  in  the  form  of  stomach- 
ics, intestinal  antiseptics  and  laxatives  may  be  administered  by  mouth, 
and  the  supply  of  nutritious  food  increased,  so  as  to  heighten  the  pa- 
tient's vitality  for  an  early  operation.     Children  convalescing  from  an 


DISEASES   OF    THE    ALIMENTARY    TRACT  275 

attack  of  nonoperated  appendicitis  should  not  be  taken  to  any  resort 
where  a  competent  snrgeon  is  not  within  immediate  reach.  Danger  al- 
ways lurks  behind  a  diseased  appendix. 

Peritonitis  Acuta 

Acute,  nontuberculous  peritonitis  is  of  rare  occurrence  in  children. 
The  primary  form  is  usually  due  to  infection  of  the  peritoneum  by  the 
B.  coli  communis,  streptococci,  staphylococci,  or  pneumococci,  or  by  a 
combination  of  them.  It  is  occasionally  also  encountered  as  a  result  of 
direct  violence  or  secondarily  in  connection  with  infectious  diseases 
e.  g.,  typhoid  fever,  scarlatina,  diphtheria,  pneumonia,  dysentery,  vulvo- 
vaginitis, appendicitis  and  extension  of  other  pus  foci.  In  the  new- 
born it  not  rarely  forms  a  partial  manifestation  of  sepsis  {q.v.). 

Acute  peritonitis  usually  sets  in  with  very  acute  symptoms:  excessive 
pain  and  tenderness  of  the  abdomen,  rapidly  developing  tympanites,  at 
first  often  diarrhea,  later  constipation,  scanty  urination,  or  complete 
anuria;  sometimes  distinctly  localized  exudation;  which  may  be  dis- 
cerned by  dulness  in  the  flanks;  high  fever,  especially  during  the  first 
few  days,  more  particularly  in  the  perforative  forms,  and  a  feeble,  rapid, 
and  very  poor  pulse ;  dry  and  brown  tongue,  anxious  and  pinched  ex- 
pression of  the  face,  and,  as  the  disease  progresses,  collapse.  As  a  rule, 
marked  leucocytosis  prevails.  The  course  of  the  disease  varies.  Hyper- 
acute peritonitis  ends  fatally  usually  in  two  or  three  days ;  moderately 
severe  cases  may  last  a  week,  and  then  terminate  either  in  death  or  in 
gradual  recovery.  To  the  latter  class  belong  also  the  cases  usually  of 
pneumococcus  origin  in  which  the  pus  becomes  encysted,  and  breaks 
through  the  umbilicus,  rectum  or  bladder. 

In  a  case  (girl  four  years  old,  ill  five  weeks)  I  recently  saw  in  con- 
sultation, the  onset  was  sudden  with  vomiting,  pain,  and  high  fever. 
These  symptoms  subsided  after  a  week,  leaving  behind  very  marked  ab- 
dominal distention,  slight,  irregular  fever,  constipation  and  distinct 
flatness  over  the  entire  lower  abdomen.  Palpation  also  revealed  very 
pronounced  enlargement  of  the  spleen.  I  concluded  that  we  were  deal- 
ing most  probably  with  a  secondary  purulent  peritonitis  and  suggested 
laparotomy,  which  would  prove  beneficial  also  were  the  case  to  turn  out 
to  be  tuberculous  peritonitis.  This  was  done  the  following  day.  Over  a 
quart  of  freely-flowing,  foul-smelling  pus  escaped  through  the  abdominal 
opening  and  the  patient  made  an  uneventful  recovery.  Apparently  the 
peritonitis  was  of  appendical  origin. 

At  all  events  the  prognosis  is  very  grave.  It  is  almost  always  fatal 
to  the  newborn,  and  in  cases  resulting  from  intestinal  perforatioti. 
Traumatic  peritonitis  offers  the  most  favorable  outcome,  and  local  peri- 


276  DISEASES  OF   CHILDREN 

tonitis  with  encapsulated  abscess  often  yields  to  prompt  and  suitable 
treatment.  Protracted  cases  may  be  complicated  by  pleurisy,  pericar- 
ditis, meningitis  and  general  pyemia. 

The  treatment,  of  course,  depends  entirely  upon  the  underlying  con- 
dition. It  is  justifiable  to  recommend  an  operation  (laparotomy)  in  all 
cases  of  acute  general  peritonitis  that  fail  to  respond  to  medical  treat- 
ment within  forty-eight  hours,  and  in  those  resulting  from  perforation 
of  an  abdominal  viscus,  e.  g.,  appendix,  intestinal  perforation  in  typhoid. 
(For  "differential  diagnosis,"  see  p.  267.) 

The  medical  treatment  consists  of  perfect  rest  for  the  body  and  im- 
mobilization of  the  intestine.  This  may  be  secured  by  the  hypodermic 
administration  of  morphine  (1/60  grain  for  a  child  two  years  old)  and 
atropine  (1/1000  grain),  the  application  of  an  ice  bag  or  light  turpentine 
stupes  to  the  abdomen,  and  discontinuance  of  any  nourishment  until  vom- 
iting has  completely  ceased.  Vomiting  is  best  arrested  by  lavage,  sodium 
bicarbonate,  bismuth  subcarbonate,  or  minute  doses  (m.  1/30)  of  tinc- 
ture of  iodine.  After  arrest  of  vomiting,  feeding  may  very  cautiously  be 
resumed.  Breast-fed  babies  may  again  be  put  to  the  breast  and  bottle-fed 
babies  should  receive  small  quantities  of  milk,  gruel,  beef  juice,  Tokay 
wine,  champaign,  and,  if  improvement  continues,  a  light  mixed  diet.  For 
excessive  tympanites,  the  long  rectal  tube  may  be  tried,  allowing  it  to 
remain  m  situ  for  hours  at  a  time.  Or  the  saline  "Murphy  drip" 
the  latter  having  the  effect  also  in  draining  the  abdomen  of  its  toxic 
products  and  acting  as  a  stimulant.  Cases  running  a  protracted  course 
sometimes  do  well  on  daily  local  inunction  of  ung.  hydrargyri  (I/2  dram), 
and  the  iodides  internally.  Localized  abscesses  should  be  incised  and 
drained.  In  slow  convalescence,  a  sojourn  at  the  seashore  will  prove 
beneficial.      (For  "Tuberculous  Peritonitis.") 

Intestinal  Worms 

Worms  gain  entrance  into  the  human  system  chiefly  through  the. 
ova,  either  consumed  with  food  and  water,  or  carried  to  the  mouth 
by  means  of  the  fingers.  We  distinguish  the  following  varieties  of 
worms : 

(a)  Oxyuris  Vermicularis  (Seat-,  Thread,  or  Pinworm). — Small, 
white,  thread-like,  freely  movable  worm,  14  to  I/2  inch  in  length.  Its 
chief  seat  is  the  rectum  where  it  causes  intense  itching.  It  may  also 
infest  the  colon,  cecum,  appendix  and  vagina  (vulvovaginitis). 

(&)  Ascaris  Lunibricoides  (Roundworm,  Nematoda). — Cylindrical, 
reddish  gray  in  color,  from  4  to  10  inches  in  length.  It  resembles  the 
earthworm  in  form.    Its  chief  seat  is  the  small  intestine,  but  it  may  mi- 


DISEASES   OF    THE    ALIMENTARY    TRACT 


277 


Fig.   62. — Oxyuris  vermicularis.     Femalo   and   male.      (After   Leuekart.) 


Fig.  63. — Ascaris  lumbricoides.     (1,  Tail  of  male;  2,  and  3,  mouth — anterior  and  pos- 
terior; 4,  excretory  pore.) 


Fig,  64. — Tenia  saginata.  a.  Natural  size  of  the  worm  at  different  sections,  b. 
Head  (with  pigment  canaliculi).  c.  Proglottides.  (Partly  after  Leuckart  and  Len- 
hartz,  F.  A.  Davis  Co.) 


278 


DISEASES   OF   CHILDREN 


grate  to  the  stomach,  gall  bladder   (icterus),  throat,  etc.,  in  the  latter 
location  occasionally  producing  attacks  of  suffocation. 

(c)   Tenice    (Tapeworms,   Cestoda). — They   are  segmented   worms   of 
variable  size.    They  inhabit  the  intestine  and  develop  by  budding. 


Fig,  65. — Tenia  solium,     a.  Head.     b.  Proglottides.     (After  Leuckart.) 


Fig.    66. — Bothriocephalus   latus.      a.  Worm,    in    sections;    natural    size.      b.  Head; 
lateral  and  front  views.     (After  Leuckart.) 


DISEASES   OF    THE    ALIMENTARY    TRACT  279 

(d)  Tenia  Mediocanellata  s.  Saginata  (Beef  Tapeworm). — It  is  sev- 
eral yards  long.  The  head  presents  at  its  middle  a  pit-like  excavation 
and  four  anterior  suckers. 

(e)  Tenia  Solium  (Fork  Tapeworm). — It  is  shorter  than  the  former. 
It  is  provided  with  four  suckers,  one  proboscis,  and  a  wreath  of  hooklets. 
After  invading  the  human  stomach,  the  liberated  embryos  may  wander 
to  various  portions  of  the  body  (skin,  heart,  brain,  and  eyes)  and  there 
develop  into  small  vesicles  (cysticercus)  and  lead  to  serious  disturbances. 

(/)  Bothriocephalus  Latus  (Fish  Tapeworm). — Several  yards  long, 
possesses  about  3,000  segments,  a  flattened  head  with  two  shallow  suc- 
tion grooves.    May  be  the  cause  of  severe  anemia. 

(g)  Tenia  Nana. — About  1  inch  long,  possesses  a  head  with  four  suck- 
ers and  a  wreath  of  hooklets.    May  cause  stubborn  diarrhea. 

(h)  Tenia  Cucumerina  s.  Elliptica. — From  5  to  15  inches  long; 
develops  from  swallowing  dog  ticks  which  infest  the  hair  of  dogs  and 
cats. 

(i)  Tenia  Echinococciis. — It  inhabits  the  intestines  of  the  dog.  The 
latter  transmits  the  ova  to  the  human  gastrointestinal  tract  through 
the  mouth,  by  licking,  etc.  The  embryos  develop  chiefly  in  the  liver  and 
lungs,  forming  cysts. 

Symptomatology. — In  times  bygone  the  laity  looked  upon  intestinal 
worms  as  the  source  of  all  ills,  and  even  the  physician  w^as  frequently 
inclined  to  hold  the  same  view.  As  a  matter  of  fact,  worms,  with  but 
few  exceptions,  rarely  produce  very  serious  disturbances.  Indeed, 
numerous  round-  and  tapeworms  may  infest  the  human  intestines 
often  without  any  indication  of  their  presence  until  accidentally  dis- 
covered in  the  stools.  Among  the  signs  which  are  otherwise  said  to 
indicate  their  presence  are  the  following:  A  pale  complexion,  black 
rings  under  the  eyes,  fetor  ex  ore,  capricious  appetite,  picking  at  the 
nose,  recurrent  urticaria,  colic,  headache,  vertigo,  apathy,  mydriasis, 
pavor  nocturnus,  grinding  of  the  teeth,  and  dry  cough.  Some  authors 
claim  to  have  observed  divers  neuroses,  convulsions,  chorea,  trismus, 
epilepsy,  amblyopia,  strabismus,  and  the  like.  The  majority  of  the  re- 
ported cases  of  this  sort,  however,  do  not  bear  close  scrutiny  and  are 
readily  traceable  to  other  causes.  The  actual  harm  done  by  some  of  the 
worms  has  been  mentioned  under  each  heading. 

Diagnosis. — The  diagnosis  can  readily  be  made  by  macro-  and  micro- 
scopic examinations  of  the  stools  and  sputum  (echinococcus  hooklets) 
for  worms  or  their  ova.  The  finding  of  intestinal  parasites  may  be 
facilitated  by  the  administration  of  anthelmintics. 


280  DISEASES   OF    CHILDREN 

Treatment. — Santonin  and  calomel  act  very  efficiently  in  thread- 
arid  roundworms. 

IJ     Santonini, 

Hydrargyri  ehloridi  mitis.  . .  .afi  gr.  vj   ]   0.4 
M.  et  div.  in  pulv.  no.  vj. 

S. — One    powder    to    be    given    every    morning,    on    an    empty 
stomach  for  a  child  three  years  old. 

To  expel  tenias  the  following  is  a  very  useful  combination: 

1^     Ext.  aspidii  fl 3iij       12 

Emulsi  chlorof ormi   3iv      15 

Mi     Emulsi  amygdalarum  ....  q.  s.  ad  5i j      60 
S. — Two  teaspoonfuls  as  a  dose  for  a  child  three  years  old,  to 
be  administered  as  follows: 

The  day  before  the  diet  should  be  restricted  to  fluids.  In  the  eve- 
ning the  patient  is  given  a  few  pieces  of  salt  herring,  followed  an 
hour  later  by  a  purgative  (castor  oil  or  calomel).  The  next  morning 
the  male  fern  should  be  administered  on  an  empty  stomach,  followed 
within  half  an  hour  by  a  dose  of  castor  oil  or  calomel.  If  only  part  of 
the  tapeworm  escapes,  and  the  other  part  remains  inside,  the  torn 
end  should  by  means  of  adhesive  plaster  be  fixed  to  the  buttocks, 
and  another  dose  of  the  anthelmintic  and  oil  administered  until  the 
rest  of  the  worm  has  been  expelled. 

The  effect  of  anthelmintics  by  mouth  is  greatly  enhanced  by  enemas 
of  soapsuds  and  turpentine  (i/^  dram  to  1  pint)  or  a  decoction  of  quassia 
wood  (1  ounce  to  1  pint).  Quassia  injections  are  very  useful  in  pin- 
worms,  especially  if  followed  by  local  application  of  gray  ointment 
In  older  children  the  fluid  extract  of  male  fern  may  preferably  be  given 
in  capsule  form.  The  rare  attacks  of  asphyxia  from  round-worms, 
previously  spoken  of,  are  best  relieved  by  turpentine  administered 
by  mouth  (on  lumps  of  sugar)  or  by  rectum,  and  prompt  expulsion  of  the 
worm  by  santonin. 

Ankylostomiasis,  Uncinariasis 

(Hookworm  Disease) 

Although  prevailing  in  this  country  for  many  years  past,  this  af- 
fection has  only  recently,  principally  through  the  efforts  of  Dr.  Charles 
W.  Stiles,  received  due  recognition  as  the  "American  murderer."  It 
is  practically  endemic  throughout  the  South,  but  is  met  with  sporadi- 
cally also  in  other  states  of  the  Union. 

The  disease  is  caused  by  the  hookworm  which  infests  the  human 
body  either  through  the  mouth  (by  swallowing  of  infected  water  or 
food),  or  through  the  skin,  especially  the  skin  of  the  feet  (the  larva 


DISEASES   OF    THE   ALIMENTARY    TRACT 


281 


of  the  worm  gradually  entering  the  circulation),  and  ultimately  set- 
tles in  the  upper  portions  of  the  small  intestines. 

The  hookworm  comprises  two  species:    Ankylostoma  duodenale  (old- 
world  species),  which  is  endemic,  especially  in  Italy  and  Egypt,  and 


Fig.    67. — Ankylostomum   duodenale.     a.   Male.     b.  Female,      c.  Head.      d.  Natural 

size.     (After  Leuckart.) 


Fig.  68. — Uncinaria  Americana,     (i,  mouth  capsule;  2,  mouth  cavity.) 

Uncinaria  americana  or  Necator  americanus  (the  new-world  species). 
Both  species  measure  from  about  ^  to  %  inch  in  length  (the  females 
somewhat  larger  than  the  males),  but  while  Ankylostoma  carries  on  its 


282  DISEASES    OF    CHILDREN 

head  four  hook-like  teeth  on  the  ventral  side  and  two  smaller  vertical 
teeth  on  the  dorsal  side,  the  Uncinaria  has  a  dorsal  pair  of  prominent 
semilunar  plates  or  lips,  and  a  ventral  pain  of  smaller  plates  of  similar 
nature. 

By  means  of  its  armed  mouth  the  worm  fixes  itself  to  the  intestinal 
mucosa,  producing  minute  erosions  and  hemorrhagic  spots,  and  sooner 
or  later  a  more  or  less  severe  catarrhal  process  in  the  alimentary  tract. 
It  is  still  a  matter  of  diversity  of  opinion  whether  the  uncinaria  feeds 
on  the  epithelial  cells  of  the  mucosa  or  upon  blood.  However  this  may 
be,  the  blood  certainly  undergoes  marked  changes,  in  severe  cases,  re- 
sembling the  blood  findings  of  primary  pernicious  anemia.  Leukocytosis 
with  eosinophilia  is  the  rule.  Very  soon  other  organs  of  the  body  are 
affected,  especially  the  liver  and  spleen. 

Postmortem  examination  usually  reveals  fatty  degeneration  of  the 
liver ;  softening  of  the  spleen  and  paucity  in  lymphoid  elements ;  neph- 
ritic changes  in  the  kidneys ;  pallor  of  the  lungs ;  flabbiness  of  the  heart, 
and  anemia  of  the  brain  and  effusion  into  the  ventricles. 

Hookworm  disease  is  most  destructive  in  the  young.  Usually  dermati- 
tis of  the  feet  and  legs  forms  the  first  symptom.  Children  remain 
stunted  in  physical  and  mental  development,  they  look  tired,  old, 
apathetic,  and  owing  to  the  puffiness  of  the  face  not  rarely  resemble 
cretins.  The  skin  is  sallow,  the  fingernails  and  the  sclerse  are  white  or 
bluish-white.  They  suffer  from  palpitation  of  the  heart,  dyspnea,  head- 
ache, dizziness,  tinnitus,  nausea,  occasionally  vomiting  and  abdominal 
pain.  The  appetite  is  either  poor  or  voracious,  often  accompanied  by 
a  desire  for  unnatural  food  (pica),  eating  of  earth,  dirt,  rags,  etc.  With 
increasing  anemia  there  is  frequently  dropsy  in  the  subcutaneous  tissues 
and  serous  cavities — the  edema  often  masking  the  emaciation  and  flabbi- 
ness of  the  body  musculature. 

Occasionally  the  disease  runs  quite  a  rapid  course,  the  patient  dying 
from  exhaustion  within  a  few  weeks. 

The  diagnosis  of  hookworm  disease  is  based  upon  a  macroscopic  and 
microscopic  examination  of  the  stools  for  the  worm  and  its  ova. 

Treatment. — Thymol  acts  specifically  in  this  affection.  It  may  be 
administered  in  an  emulsion  with  acacia  or,  in  older  children,  in  the 
form  of  capsules,  the  thymol  crystals  being  first  triturated  with  sugar 
of  milk.  The  following  mode  of  administration  is  recommended: 
Late  in  the  afternoon  the  patient  receives  2  grains  of  calomel  (no  cas- 
tor oil)  and  the  next  morning  1  dram  of  Epsom  salts.  After  the  bowels 
have  thoroughly  acted,  5  or  10  grains  of  the  thymol  is  given  on  an 
empty  stomach,  and,  if  indicated,  the  dose  is  repeated  after  an  hour. 


DISEASES   OF    THE    ALIMENTARY    TRACT  283 

The  patient  is  kept  in  bed,  without  food,  until  late  in  the  afternoon. 
Some    clinicians    recommend    oil    of    chenopodium    instead    of    thymol. 
The  feces  should  again  be  examined  for  uncinaria  after  the  lapse 
of  from  two  to  four  weeks. 

DISEASES  OF  THE  LIVER 
Icterus  Catarrhalis 

(Catarrhal  Jaundice) 

Catarrhal  icterus  (catarrh  of  the  ductus  choledochus)  occurs  as  fre- 
quently in  children  over  four  years  of  age  as  in  adults.  It  is  compara- 
tively rare  in  infants,  except  in  the  newborn.  (See  p.  231.)  As  a  rule, 
it  is  caused  by  and  associated  with  gastroduodenal  catarrh,  and  begins 
with  coated  tongue,  anorexia,  nausea,  vomiting,  and  slight  rise  of  tem- 
perature. (In  another  group  of  cases  which  is  of  microbic  origin  (epi- 
demic icterus  or  Weil's  disease),  the  onset  is  sudden,  with  high  fever, 
apathy,  delirium,  headache,  and  vomiting,  so  that  before  the  appearance 
of  the  icterus  cerebral  disease  is  first  thought  of.)  In  a  day  or  two  it  is 
usually  found  that  the  urine  is  brownish  yellow  (bile  stained),  the  fe- 
ces are  gray  and  clayey,  and  the  conjunctivge,  sclerse  and  skin  yellow 
in  color.  This  pathognomonic  group  of  symptoms  increases  in  intensity 
up  to  about  a  week,  and  then  begins  to  diminish,  first  with  clearing  of 
the  urine.  The  pulse  is  usually  retarded,  about  seventy  beats  to  the 
minute  when  the  child  is  at  rest.  Palpation  and  percussion  reveal 
tenderness  over  the  stomach  and  liver,  and  occasionally  some  enlarge- 
ment of  the  latter.  This  is  particularly  the  case  in  catarrhal  jaundice 
running  a  protracted  course. 

The  prognosis  is  favorable  and  under  suitable  treatment  the  symp- 
toms ordinarily  subside  within  from  ten  to  fourteen  days.  The  treat- 
ment consists  of  restriction  of  diet  to  thin  soups,  albumin  water,  skim- 
med milk,  tea  and  toast,  boiled  fish  or  chicken,  and  similar,  easily  di- 
gestible food,  free  from  fat  (no  cream,  eggs  or  pastries!).  Grad- 
ual return  to  a  heavier  diet.  Medicinally,  a  few  small  doses  of  calomel 
and  bicarbonate  of  soda,  and  daily  intestinal  irrigation  (with  2  quarts 
of  water  at  90°  F.)  will  usually  suffice  to  arrest  the  disease.  Pancreatin, 
rhubarb  and  soda  mixture,  and  sodium  salicylate  are  useful  remedies, 
and  prolonged  warm  alkaline  baths  (1  pound  of  bicarbonate  of  soda  to 
the  bath)  hasten  recovery  in  chronic  cases. 

Diseases  of  the  Parenchyma  of  the  Liver 

Primary  disease  of  the  parenchyma  of  the  liver  is  extremely  rare  in 
children  under  twelve  years  of  age,  since  its  principal  cause — alcohol- 
ism— is  practically  unknown  in  young  children.     On  the  other  hand. 


284  DISEASES  OF   CHILDREN 

secondary  involvement  of  the  liver  is  not  infrequently  met  with  in 
connection  with  syphilis,  tuberculosis,  chronic  suppurative  processes, 
malaria,  rachitis,  valvular  heart  disease,  protracted  gastrointestinal 
disease,  and  infectious  fevers.  In  these  conditions  the  symptomatol- 
ogy is  the  same  as  in  adults. 

Cirrhosis  of  the  Liver 

1.  Atrophic  Cirrhosis. — After  a  prodromic  stage  of  several  weeks, 
consisting  chiefly  of  gastrointestinal  disturbances,  emaciation,  tym- 
panites, ascites,  slight  enlargement  of  the  spleen,  and  dilatation  of  the 
abdominal  veins  gradually  complete  the  clinical  picture  of  the  disease. 
The  atrophy  of  the  liver  usually  sets  in  insidiously,  as  a  result  of 
gradual  hardening  and  contraction  of  the  connective  tissue.  The  course 
of  the  disease  is  shorter  in  children  than  in  adults.  Hemorrhages  from 
the  stomach  and  nose  and  into  the  skin  not  rarely  occur  toward  the 
end  of  the  disease,  and  progressive  ascites  hastens  fatal  termination. 

Case  Eeport. — 0.  H.,  male,  six  years  of  age,  was  of  healthy  German  parents. 
When  barely  a  few  months  old  he  was  frequently  given  a  taste  of  beer,  to  initiate 
him,  as  it  were,  in  the  national  custom.  He  liked  it  immensely  from  the  start, 
and  as  he  grew  older  this  beverage  served  very  handily  as  a  prompt  pacifier  to  sub- 
due his  ungovernable  temper.  He  was  breast  fed  up  to  twenty  months,  and  when 
he  was  weaned  he  stubbornly  refused  to  drink  cow's  milk.  Beer  again  proved 
the  most  alluring  substitute.  It  was  given  to  him  either  cold,  mixed  with  the  yolk 
of  an  egg,  or  in  the  form  of  " Bier-Suppe,"  i.e.,  boiled  beer  Avith  small  squares  of 
toasted  rye  bread.  The  boy  did  exceedingly  well  for  several  years.  At  last  he  began 
to  suffer  from  frequent  attacks  of  indigestion.  Every  article  of  food  Avas  blamed 
for  his  upset  stomach  except  the  beer;  and,  as  on  the  advice  of  the,  family  physician, 
his  diet  was  restricted  to  the  limit  barely  to  sustain  his  life,  beer  again  stood 
him  in  good  stead  in  times  of  distress.  When  I  saw  him  he  was  greatly  emaciated. 
His  abdomen  was  immensely  enlarged,  very  tense  and  traversed  by  large  tortuous 
veins,  and  revealed  the  presence  of  a  large  quantity  of  fluid.  It  was  utterly  impos- 
sible to  palpate  the  intraabdominal  organs.  I  withdrew  about  three  pints  of  clear, 
yellowish  fluid,  and  was  then  enabled  to  determine  the  absence  of  any  growth  or  tume- 
faction in  any  portion  of  the  abdominal  cavity,  and  the  great  reduction  in  the  size 
of  the  liver. 

2.  Hypertrophic  Cirrhosis. — This  disease  is  characterized  by  consid- 
erable enlargement  of  the  liver,  pronounced  icterus,  very  marked  en- 
largement of  the  spleen,  and  a  protracted  course.  Ascites  is  absent 
until  very  late.  The  children  usually  remain  stunted  in  growth.  The 
liver  is  of  very  hard  consistence. 

3.  Cong-estive  Cirrhosis  (Cardiac  Cirrhosis,  Cardiotuberculous  Cir- 
rhosis).— Pathologically  it  is  characterized  by  hypertrophy  of  the 
liver  and  spleen,  obliteration,  of  the  pericardium,  and  by  tuberculous 
pleuritis  and  peritonitis.  Intense  ascites  forms  the  principal  clinical 
symptom. 


DISEASES   OF   THE   AUMENTARY   TRACT  285 

4.  Sugar-Cake  or  Sugar-coated  Liver  (Pericarditic  Pseudocirrhosis 
of  the  Liver — Pick's  Disease). — This  form  of  liver  disease  is  closely 
allied  to  the  former  variety.  It  is  a  progressive,  incurable  affection 
of  unknown  etiology. 

Treatment. — Since  small  quantities  of  spirituous  liquors  have  proved 
to  be  the  cause  of  quite  a  few  cases  of  hypertrophic  cirrhosis  of  the  liver 
in  children,  it  is  essential  to  interdict  its  use  in  children,  unless  in- 
tended for  temporary  therapeutic  purposes. 

The  iodides  and  mercury  should  be  given  a  fair  trial  in  all  forms  of 
cirrhosis  irrespective  of  cause.  The  ascites  may  be  relieved  by  tap- 
ping, if  diuretics,  cathartics  and  heart  stimulants  fail  to  do  so.  Bland 
diet.     Sojourn  at  the  seashore. 

Acute  Yellow  Atrophy 

Its  course  is  very  violent,  sometimes  ending  fatally  within  a  few 
days.  The  symptomatology  is  the  same  as  in  the  adult :  high  fever, 
icterus,  hematemesis,  bloody  stools,  cerebral  symptoms. 

Fatty  Liver 

Anemia  and  emaciation  are  the  principal  symptoms.  The  liver  is 
often  moderately  enlarged.  The  stools  are  grayish,  past}'.  The  course 
is  chronic. 

Amyloid  Liver 

It  is  often  associated  with  amyloid  degeneration  of  the  spleen  and 
kidneys,  and  secondary  to  some  wasting  disease,  especially  chronic 
suppurative  processes  in  the  bones  and  joints.  The  hepatic  and 
splenic  dulness  is  enlarged,  but  pain  on  pressure,  jaundice,  or  ascites 
are  absent,  unless  the  portal  circulation  is  interfered  with  by  enlarge- 
ment of  the  glands  in  the  portal  fissure. 

Attention  to  the  cause,  and  to  the  dietetic  and  hygienic  measures, 
may  prove  effective  to  arrest  the  degenerative  process. 

Abscess  of  the  Liver 

This  condition  is  occasionally  observed  in  children,  most  frequently 
as  a  result  of  extension  of  septic  processes  from  neighboring  structures, 
e.  g.,  suppurative  appendicitis,  phlebitis  umbilicalis,  typhoid  or  dysen- 
teric intestinal  ulceration.  It  may  follow  traumatism,  invasion  by  round- 
worms, suppuration  of  echinococcus  cysts,  or  of  the  mesenteric  glands. 
The  abscess  may  perforate  into  the  thorax,  intestines,  or  externally. 

Symptomatology. — Chills,  hectic  fever,  tenderness  over  the  liver; 
sometimes  fluctuation  and  pus  on  aspiration. 


28G 


DISEASES   OF   CHILDREN 


Treatment. — Free  incision  and  evacuation  of  the  pus  as  soon  as  the 
diagnosis  has  been  established. 


Tumors  of  the  Liver 

Benign,  as  well  as  malignant,  tumors  of  the  liver  are  occasionally 
observed  in  young  children  and  even  in  the  newborn.  Cystic  degen- 
eration is  most  common,  and  cases  of  carcinoma,  adenocarcinoma 
and,  more  rarely,  sarcoma  are  on  record.  These  growths  should 
not  be  confounded  with  gumma  of  the  liver — a  positive  Wassermann 
reaction  and  the  effect  of  specific  treatment  being  most  decisive  in  the 
diagnosis. 

Differential  Diagnosis 


LIVER 

HYDATID     CYST 

PLEURISY     WITH 

SOLID    TUMOR 

ABSCESS 

OP    THE    LIVER. 

EFFUSION 

OF   THE   LIVER 

Chills   

Marked 

Absent 

Slight 

Absent 

Fever   

Hectic 

Absent 

Moderate 

Absent 

Tenderness    

Marked 

Absent 

Absent 

Moderate 

Icterus  

Slight,  early 

Late 

Absent 

Marked,  late 

Fluctuation 

Moderate 

Pronounced 
"hydatid 
vibration ' ' 

Absent,    diffuse 
flat  area,  un- 
influenced   by 
inspiration 

Absent 

Dulness    

Highest  in  mid- 
axillary   line 

Highest  in  mid- 
axillary  line 

Lowest  in  mid- 

Irregular 

axillary  line 

Aspiration   reveals 

Pus 

Nonalbuminous 
fluid  with 
' '  hooklets ' ' 

Albuminous 
fluid  which 
coagulates  on 
boiling.      Pus 
in   pyothorax 

Blood 

Lung  symptoms  . 

Absent 

Absent 

Present 

Absent 

CHAPTER  VI 

DISEASES  OF  THE  RESPIRATORY  SYSTEM 

General  Remarks 

The  inherent  frailty  of  the  infantile  respiratory  tract  is  very  con- 
ducive toward  its  morbidity.  The  nasopharyngeal  passages  being 
very  narrow  and  Avinding — intended  to  halt  air  impurities  and  to 
moisten  and  warm  the  inspired  air  before  its  entrance  into  the  larynx 
— functionate  to  their  own  detriment  in  localities  where  the  air  is 
dust-,  smoke-  and  dirt-laden,  and  where  atmospheric  changes  are 
many  and  marked.  Thus,  the  child  being  unable  to  clear  its  nose, 
the  detained  foreign  bodies  irritate  the  delicate,  highly  vascular 
mucous  membrane,  before  long  forming  a  nidus  for  bacterial  inva- 
sion. As  we  shall  see  later,  "a  cold  in  the  head"  is  quite  common 
in  infants,  and,  while  per  se  harmless  in  its  immediate  effect,  is  often 
serious  in  its  remote  results.  The  local  congestion  by  its  repeated  re- 
currence produces  a  locus  minoris  redstentim  not  only  of  the  mucous 
membrane  of  the  nose,  but,  by  extension  and  persistence,  of  the  in- 
flammatory changes  (hypertrophy),  of  the  pharynx  and  adenoid  tissue 
as  well.  With  ensuing  nasopharyngeal  obstruction  breathing  now  pro- 
ceeds principally  through  the  mouth;  the  air  no  longer  undergoes  the 
preparatory  process  of  filtration,  moistening  and  warming,  but  reaches 
the  larynx  in  its  impure,  irritating  state,  sooner  or  later  giving  rise  to 
a  catarrhal  inflammation  of  the  larynx  and  neighboring  structures. 
This  condition  is  soon  aggravated  by  the  continuous  aflfluxion  of  foul 
nasopharyngeal  secretion,  and  by  the  inability  of  the  little  patient  to 
clear  its  throat  by  forceful  expectoration.  Furthermore,  the  thorax 
being  short  and  narrow,  its  musculature  thin  and  feeble,  and  the  heart 
and  thymus  gland  comparatively  large,  the  more  or  less  compressed  lung 
is  greatly  hampered  in  free  aeration  and  in  ridding  its  distantly  located 
portions  of  the  obnoxious  inflammatory  products.  Hence  the  pertinac- 
ity of  apparently  insignificant  pulmonary  lesions,  the  frequency  of  un- 
resolved pneumonia  and  pyothorax,  and  the  insidious  development  of 
asthma,  bronchiectasis  and  emphysema.  As  the  child  grows  older,  the 
nasopharyngeal  tract  larger,  the  thoracic  cavity  more  spacious  and,  syn- 
chronously, the  respiratory  function  more  forceful,  there  is  a  correspond- 
ing reduction  in  the  frequency  and  persistency  of  respiratory  disease,  not- 
withstanding, or,  perhaps,  because  of  the  increased  exposure  of  the  child 
to  atmospheric  changes  and  infection. 

287 


288  DISEASES   OF    CHILDREN 

DISEASES  OF  THE  NOSE  AND  THROAT  AND  EAR 

Rhinitis  Acuta 

(Coryza) 

Acute  coryza  is  a  frequent  affection  of  childhood.  It  may  occur 
primarily  as  a  result  of  bacterial  infection  or  follow  exposure  to  ther- 
mic, mechanic  or  chemic  irritation,  or  set  in  in  association  with  measles, 
influenza,  scarlatina  and  diphtheria.  The  infectious  variety  often  oc- 
curs in  epidemic  form. 

Primary  coryza,  if  mild  in  character,  gives  rise  to  sneezing,  slight 
rise  of  temperature,  anorexia,  etc.  On  the  other  hand,  if  severe  in 
form,  especially  in  infants,  it  usually  begins  with  vomiting,  fever,  oc- 
clusion of  the  upper  air  passages  by  mucous  or  mucopurulent  secretion, 
secondary  conjunctivitis,  and  sometimes  with  convulsions.  Owing  to 
thickening  of  the  nasal  mucous  membrane  there  is  partial  or  total  ob- 
struction to  nasal  breathing,  giving  rise  to  interference  with  suckling, 
dyspnea,  and  even  acute  attacks  of  asphyxia.  The  latter  are  prone  to  oc- 
cur especially  in  the  newborn  who  are  very  apt  to  ''swallow"  the  tongue. 

Every  case  of  acute  rhinitis  associated  with  severe  local  (pseudo- 
membranous deposit)  and  systemic  (vomiting,  rapid  loss  of  strength) 
symptoms  should  arouse  the  suspicion  of  being  diphtheritic  or  scarla- 
tinal in  character. 

Acute  rliinitis  is  not  rarely  complicated  by  otitis,  laryngitis  and  bron- 
chitis and  exceptionally  by  sinusitis  (in  older  children).  The  prognosis 
is  generally  good,  although  in  young  infants  convalescence  is  slow. 

Treatment. — Avoidance  of  exposure  to  all  atmospheric  changes, 
even  as  regards  temperature  in  the  room.  Cleansing  of  the  nostrils  by 
repeated  instillation  of  a  few  drops  of  a  2  per  cent  solution  of  bicar- 
bonate of  soda,  alternated  with  lukewarm  mentholated  olive  oil  or 
albolene.  Careful  feeding,  if  necessary,  by  the  spoon.  As  measures  of 
temporary  relief,  we  may  recommend  local  applications  of  atropine  (1/4 
per  cent),  cocaine  (1  per  cent),  or  suprarenal  solutions  (^o  per  cent), 
and  camphor  and  the  salicylates  and  quinine  internally.  There  should 
be  more  or  less  strict  isolation  of  the  patient.  Attention  should  be  paid 
to  constitutional  symptoms.  Serum  therapy,  whenever  it  is  indicated 
(diphtheria). 

IJ     Natrii  salicyl   gr.  xii      0.8 

Pulv.  eamphorse gr-  iii      0-2 

Chocolate     q.  s. 

M.  Div.  in  pulv.  no.  iv. 
S. — One  powder  every  two  hours  for  a  child  three  years  old. 


DISEASES   OF   THE   RESPIRATORY   SYSTEM  289 

Rhinitis  Chronica 
(Nasal  Catarrh,  Ozena) 

It  is  characterized  by  marked  congestion  and  thickening  of  the  nasal 
mucous  membrane  and  hypersecretion — hypertrophic  rhinitis,  or  by 
atrophy  of  the  various  layers  of  the  mucous  membrane  and  foul-smell- 
ing incrustation — atrophic  rhinitis,  ozena.  The  latter  form  is  rarely 
observed  in  children  under  ten  years  of  age.  In  the  nursling  it  is  often 
due  to  h-mphatism  or  more  rarely  to  hereditary  syphilis  (syphilitic 
rhinitis). 

Chronic  rhinitis  is  usually  the  result  of  repeated  attacks  of  acute 
coryza  or  other  affections  of  the  nasopharynx  associated  with  nasal 
hypersecretion  and  obstruction  to  free  nasal  breathing  (adenoids).  In 
the  presence  of  foreign  bodies  in  the  nose,  the  catarrh  is  usually  uni- 
lateral. The  disease  is  generally  manifested  by  persistent  coughing, 
enlarged  lymph  nodes  at  the  angle  of  the  jaw,  oral  breathing  and  other 
symptoms  which  usually  accompany  adenoids  (q.v.). 

Treatment. — As  all  forms  of  chronic  rhinitis  by  respiratory  inter- 
ference and  secondary  glandular  infection  give  rise  to  more  or  less 
impairment  of  the  constitution,  the  treatment  of  this  condition  should 
embrace  local,  as  well  as  general,  therapeutic  measures.  The  naso- 
pharynx should  be  kept  clean  by  antiseptic  and  oily  sprays  and  the 
congestion  allayed  by  painting  the  mucous  membrane  twice  or  three 
times  a  week  with  5  to  10  per  cent  of  arg^^rol  or  solargentum,  or  tannin- 
glycerine,  etc.  Excessive  hypertrophy  should  be  reduced  by  trichlor- 
acetic acid  and  similar  caustics,  and,  if  these  fail,  by  means  of  the 
galvanocautery  or  nasal  scissors.  In  older  children  correction  of  de- 
viated septum. 

IJ   Thymolis   gr  ii  I    0.15 

Olei  eucalypti    m  v       0.3 

Albolene q.  s.  ad  S  ii  |  60.0 

M.  , 

S. — Nosespray,  to  be  used  morning  and  evening. 

Epistaxis 

(Hemorrhage  from  the  Nose,  Nosebleed) 

Bleeding  from  the  nose  may  be  due,  primarily,  to  traumatism,  ex- 
ternal irritation  of  the  mucous  membrane  from  various  causes,  foreign 
bodies,  etc. ;  or  it  may  occur  as  a  result  of  vascular  excitement  during 
the  course  of  febrile  (typhoid,  pneumonia),  circulatory  (especially  after 
exertion)  and  pulmonary  diseases;  and  hemorrhagic  affections  (hemo- 
philia, leukemia).    In  girls  it  may  occur  as  vicarious  menstruation. 


290  DISEASES    OF    CTI1ED1?EN 

Treatment. — The  treatment  of  epistaxis  varies,  of  course,  with  the 
cause.  In  slight  hemorrhage,  simple  compression  of  the  aliE  nasi 
against  the  septum  acts  efficiently.  A  bland  ointment  introduced  in 
the  nares  before  the  child  retires  will  usually  prevent  recurrence  of 
the  bleeding. 

In  case  of  moderate  bleeding,  sitting  posture,  head  erect,  with  hands 
folded  over  the  head,  and  ice  application  to  the  nose  and  nape  of  the 
neck,  or  instillation  of  cold  "water  (with  some  lemon  juice,  vinegar, 
alum  or  potassium  permanganate)  into  the  nose  will  usually  suffice. 
If  this  fails,  the  nares  should  be  packed  as  far  back  as  possible  with 
pledgets  of  cotton  or  gauze,  dipped  in  a  strong  solution  of  alum, 
peroxide  of  hydrogen,  or  suprarenal  gland  solution.  In  secondary 
epistaxis  due  to  vascular  congestion,  a  small  dose  of  morphine  hypo- 
dermically  in  conjunction  with  the  aforementioned  measures  will 
often  act  very  promptly.  As  the  last  resort,  we  turn  to  the  postnasal 
tampon,  which,  as  a  rule,  checks  the  hemorrhage  unless  hemophilia 
is  the  underlying  condition  of  the  bleeding,  when  the  treatment  must 
be  directed  chiefly  against  this  affection  (q.v.). 

Detection  of  the  local  causes  is  very  essential.  Every  visible  bleed- 
ing spot  should  be  cauterized  with  chromic  or  nitric  acid  or  with  the 
galvanocautery.  Constitutional  symptoms,  if  present,  should  receive 
prompt  attention. 

Tumors  and  Foreign  Bodies  in  the  Nose 

Mouth  breathing,  snoring,  and  nasal  speech  are  not  due  solely  to 
adenoid  vegetations  or  large  tonsils.  Not  infrequently  obstruction  to 
breathing  is  the  result  of  the  presence  of  mucous  polypi  (soft,  jelly- 
like), fibrosarcomas  (hard  and  pedunculated),  or  foreign  bodies.  The 
latter  are  usually  beans,  pebbles,  cherry  stones,  and  so-called  rhino- 
liths.  Sooner  or  later  they  give  rise  to  a  (unilateral)  foul,  bloody  dis- 
charge and  implicate  the  lacrimal  duct  and  Eustachian  canal,  and  form 
a  reflex  cause  of  persistent  irritable  cough  and  asthmatic  symptoms. 
The  diagnosis  can  readily  be  made  by  inspection  or  x-ray  examination. 

Treatment. — Tumors  should  be  removed  with  the  cold  snare,  gal- 
vanocautery, or  by  torsion  with  a  slender  forceps.  Bleeding  may  be 
arrested  in  the  manner  outlined  above. 

Foreign  bodies  if  anteriorly  situated  can  readily  be  removed  by 
air  inflation  through  the  free  side,  or  by  means  of  a  pointed  forceps. 
If  impacted  farther  back,  it  is  preferable  to  dislodge  the  foreign  body 
with  a  slender  hook  or  forceps  under  cocaine,  and  either  extract  it 
anteriorly  or  force  it  posteriorly  into  the  nasopharynx. 


DISEASES    OP    THE    RESPIRATORY    SYSTEM 


291 


Fig.  69. — Toy  ring  in  antral  cavity  giving  rise  to  empyema  of  tlic  antrum  of  High- 
more  in  a  child  three  years  old. 


Sinusitis 

In  children  over  five  years  of  age,  exceptionally  in  younger  ones,  we 
occasionally  meet  with  infections  in  the  accessory  sinuses  in  connec- 
tion with  severe  rhinitis,  influenza,  infected  adenoids,  etc.  In  the 
acute  stage  the  children  usually  complain  of  pain  at  the  seat  of  the 


292  DISEASES   OP   CHILDREN 

lesion,  headache  and  occasionally  dizziness.  There  is  generally  also 
a  more  or  less  profuse  purulent  discharge  (unilateral  if  only  one  side 
is  affected).  In  chronic  cases  the  symptoms  are  usually  masked  and  may 
be  mistaken  for  those  of  rhinitis  or  adenoids.  In  doubtful  cases  the 
Roentgen  ray  will  readily  clear  up  the  diagnosis. 

These  cases  are  best  managed  by  removal  of  underlying  causes,  spe- 
cial attention  to  cleanliness  of  the  nasopharynx,  instillations  of  argy- 
rol,  etc. ;  if  these  measures  fail,  the  patient  should  be  intrusted  to 
the  care  of  a  rhinologist. 

Neglect  of  sinusitis  may  not  rarely  lead  to  serious  consequences 
(meningitis!). 

Pharyngitis  Acuta 

Acute  pharyngitis  is  rarely  primary  (streptococcic  infection),  but 
quite  frequently  secondary  in  nature  as  a  complication  of  acute  rhi- 
nitis, tonsillitis,  acute  exanthematous  affections,  etc.  Primary  pharyn- 
gitis is  ordinarily  of  short  duration  and  manifested  by  dryness  in  the 
pharynx,  pain  in  swallowing,  and  moderate  rise  of  temperature.  The 
pharynx  is  reddened,  somewhat  swollen,  and  often  granular. 

Secondary  pharyngitis  will  be  considered  in  connection  w'ith  the 
diseases  it  complicates. 

Treatment. — Attention  to  the  bowels,  rest  in  bed,  Priessnitz  com- 
presses to  the  neck  and  antiseptic  sprays  to  the  throat.  Liquid  non- 
irritating  diet. 

Pharyngitis  Chronica 

It  may  develop  after  repeated  attacks  of  acute  pharyngitis  or  as  a 
result  of  extension  of  an  inflammation  from  the  adjacent  structures. 
The  posterior  pharyngeal  wall  not  rarely  presents  a  deeply  congested 
granular  appearance,  and  is  here  and  there  covered  by  a  tenacious 
mucous  deposit. 

The  affection  is  associated  with  more  or  less  dryness  in  the  throat, 
hawking  and  coughing.  On  examination,  the  fauces  appear  swollen 
and  relaxed,  the  tonsils  hypertrophied,  and  the  esophageal  opening 
covered  by  a  thick,  grayish-white  deposit. 

Treatment. — Avoidance  and  removal  of  causes.  Locally  the  parts 
must  be  kept  clean  by  mild  antiseptic  sprays  (Dobell's  solution),  and 
the  swelling  reduced  by  nasal  instillations  of  a  5  to  10  per  cent  solu- 
tion of  argyrol,  silvol  or  solargentum,  or  by  painting  the  throat  with 
tannin-glycerine  (5  per  cent).  Change  of  air,  iodide  of  iron,  cod  liver 
oil,  etc.,  are  very  helpful  to  effect  a  cure. 


Angina  Folijcularis 


Angina  Herpetiformis,   After  Vesicl 
Burst 


Angina  Ulcerosa  (Vincentii) 
PLATE  V 

{Courtesy  of  Dr.  John  Zahorsky.) 


DISEASES   OF    THE   RESPIRATORY    SYSTEM  293 

IJ     Suprarenal  solution  (1:2000), 

Dobell's  solution    aa  5  i  |  30.0 

M. 

S. — Throat  spray  in  acute  or  chronic  pharyngitis. 

Angina 
(Sore  Throat) 
Tonsillitis  Acuta,  Amygdalitis,  Quinsy- 
Children  under  two  years  of  age  seem  to  present  a  decided  im- 
munity against  tonsillitis.  On  the  other  hand,  all  forms  of  angina 
are  extremely  common  in  children  over  two  years  old.  .  Those  with 
a  "catarrhal  habit"  are  especially  prone  to  contract  the  disease. 
Streptococci,  staphylococci  and  pneumococci  among  other  micro- 
organisms, form  the  most  frequent  primary  cause,  and  are  productive 
of  the  usual  symptom  complex  which  is  characteristic  of  similar  con- 
tagious and  infectious  diseases  of  childhood.  Thus,  the  attack  is 
ushered  in  suddenly  with  a  chill,  rise  of  temperature  (with  evening 
exacerbations),  vomiting  (in  younger  children)  and  sometimes  con- 
vulsions. The  younger  the  child  the  less  conspicuous  the  dysphagia. 
Hence  the  importance  of  a  routine  examination  of  the  throat  in  all 
febrile  affections. 

To  avoid  unnecessary  repetition,  it  is  advantageous  to  classify  ton- 
sillitis in  accordance  with  the  tonsillar  deposit  as  follows: — 

1.  Angina  Catarrhalis. — Eedness  and  swelling  of  one  or  both  faueial 
tonsils  and  adjacent  tissues.    Thin  mucous  exudation. 

2.  Angina  FoUicularis. — The  deposit  begins  as  one  or  more  white, 
small  pellicles  upon  the  middle  or  anterior  portion  of  the  tonsil.  The 
white  dots,  at  first  distinctly  isolated,  soon  coalesce  to  form  yellow- 
ish- or  greenish-white,  elevated  patches.  These  are  removable  without 
profuse  bleeding,  and  reform  slowly. 

3.  Angina  Epidemica  (Septic  Sore  Throat). — The  most  common  ap- 
pearance is  that  of  follicular  tonsillitis,  but  the  constitutional  symp- 
toms are  much  more  severe  and  there  is  usually  marked  involvement 
of  the  cervical  lymph  nodes  and  a  tendency  to  metastatic  infection 
in  remote  parts  of  the  body.  Nausea,  vomiting  and  other  gastrointes- 
tinal symptoms  often  predominate.  It  occurs  in  epidemics  and  is 
usually  traceable  to  infected  milk.  According  to  C.  H.  Dunn,  septic 
angina  may  be  complicated  by  peritonsillar  abscess,  suppuration  of 
the  cervical  lymph  nodes,  arthritis,  peritonitis,  pleurisy,  pericarditis, 
pneumonia,  laryngitis,  endocarditis,  phlebitis,  nephritis,  and  septice- 
mia. 


294  DISEASES   OF    CIIILDKEN 

4.  Angina  Parenchymatosa  (Quinsy,  Peritonsillar  Abscess). — The 
tonsil  (usually  one)  and  peritonsillar  tissue  are  intensely  swollen,  often 
displacing  the  uvula.  It  is  bluish  in  color  and  doughy  in  consistency. 
The  deposit,  at  first  Avhite,  gradually  turns  yellowish-green,  resembling 
the  "point"  of  an  abscess.    Pus  on  puncture. 

5.  Angina  Herpetiformis. — The  deposit  begins  with  minute  vesicles, 
which  tend  to  burst  and  leave  behind  superficial  ulcers.  This  form 
of  amygdalitis  usually  involves  both  tonsils  and  is  at  times  complicated 
by  stomatitis. 

6.  Angina  Gangrenosa  (Necrotica). — The  tonsils  are  moderately  en- 
larged and  almost  completely  covered  by  a  greenish-yellow,  continu- 
ous, deposit  surrounded  by  a  red  zone.  The  exudation  if  removed 
leaves  behind  a  deeply  seated  ulcer.  The  deposit  often  spreads  from 
one  tonsil  to  the  other  by  way  of  the  anterior  pillars,  palatine  arch 
and  uvula. 

7.  Angina  Ulcerosa  (Vincenti). — It  greatly  resembles  the  latter 
but  is  usually  limited  to  one  tonsil,  and  occasionally  presents  a  pseu- 
domembrane.  It  is  often  associated  with  stomatitis.  Vincent's  bacillus 
in  pure  culture  is  almost  always  found  in  the  exudation. 

The  course  of  tlie  different  varieties  of  tonsillitis  varies  but  slightly. 
After  subsidence  of  the  acute  initial  symptoms  previously  spoken  of, 
the  disease  assumes  a  much  milder  aspect,  except  as  to  prostration, 
pain  on  swallowing,  and  evening  exacerbations  of  the  fever.  The 
latter  ranges  between  102°  and  105°  F.,  and  is  especially  high  in  fol- 
licular tonsillitis.  More  or  less  marked  lymphadenitis  is  present  in 
all  forms  of  angina,  and  in  accordance  with  the  tonsillar  involvement 
it  is  either  unilateral  or  bilateral.  Parenchymatovis  angina  is  not  in- 
frequently associated  with  pseudotorticollis,  and  pain  on  moving  the 
jaws  is  present  also  in  the  other  forms  of  the  affection. 

In  uncomplicated  cases,  recovery  is  the  rule  in  from  three  to  ten 
days,  but  quite  a  number  of  deviations  from  the  usual  course  are  ob- 
served. Ulcerative  angina  usually  lasts  from  two  to  three  weeks. 
Tonsillitis  is  not  rarely  the  forerunner  of  true  diphtheria  or  rheu- 
matic affections  with  their  respective  complications,  and  cases  are 
on  record  where  it  has  proved  to  be  the  source  of  general  septic  or 
pyemic  infection. 

Differential  Diagnosis. — Angina  may  be  confounded  with  influenza, 
glandular  fever,  diphtheria  and  scarlatina.  In  influenza  the  exudation 
is  slight  and  not  strictly  limited  to  the  tonsils ;  marked  adenitis  is  com- 
paratively rare.  Furthermore,  influenza  is  characterized  by  the  simul- 
taneous presence  of  respiratory,  digestive,  and  often  nervous  phenomena, 
while  in  tonsillitis  throat  symptoms  predominate.     Glandular  fever  dif- 


DISEASES    OF    THE    RESPIRATORY    SYSTEM  295 

fers  from  tonsillitis  by  the  comparative  absence  of  tonsillar  manifestations 
and  preponderance  of  »landnlar  swelling  (also  of  the  bronchial,  esopha- 
geal and  retroperitoneal  glands).  The  distinction  between  severe  eases  of 
tonsillitis  and  moderately  severe  forms  of  diphtheria  without  a  becterio- 
logic  examination  is  often  very  difficult  in  the  first  twenty-four  hours  of 
the  disease.  In  pharyngeal  diphtheria  the  pseudomembranc  appears  as  a 
small  uneven,  grayish  white,  slightly  elevated  patch  upon  the  inner 
tonsillar  or  faucial  surfaces  of  the  throat.  The  deposit  augments  by 
rapid  spreading,  within  a  few  hours  reaching  the  posterior  wall  of  the 
pharynx  and  adjacent  structures.  The  surrounding  uncovered  areas 
are  grayish  in  color,  due  to  overcrowding  of  leucocyte  nuclei  and  mucus 
beneath.  The  tonsils  are  only  moderately  large  in  size,  but  the  sub- 
maxillary glands  are  large  and  hard,  assuming  the  shape  of  a  large 
walnut,  and  bulge  conspicuously  forward.  The  deposit,  if  removed, 
leaves  a  raw,  bleeding  surface  and  rapidly  reaccumulates.  Diphtheria 
bacilli  are  found  in  the  throat.  Tonsillitis  with  and  even  without 
erythema  may  be  mistaken  for  scarlatinu,  and  a  differential  diagnosis 
is  sometimes  impossible  until  a  few  days  after  the  beginning  of  the 
attack. 

Treatment. — In  view  of  the  possible  serious  complications,  tonsilli- 
tis should  be  arrested  at  its  inception.  The  following  mixture  should 
be  used  every  two  hours  as  a  local  application,  either  undiluted,  by  means 
of  a  cotton  swab  in  young  children,  or  diluted  .1  to  20  of  water,  as  a 
gargle,  in  older  ones : 


IJ     Eesorcini    3  ss 


2.0 


Acicli  carbolic! gr  xx  1.3 

Pulveris  camphorae gr  x  0.6 

Alcoholis    3ii  8.0 

Glycerini    q.s.   ad   3   ii  60.0 

M. 
S. — One   teaspoonful  in  twenty   of  water   as   a 
gargle  every  two  hours,  etc. 

For  the  relief  of  pain,  cold  Priessnitz's  compresses  or  an  ice-collar 
to  the  neck,  and  salicylates  internally.  The  latter  is  intended  also  to 
guard  against  rheumatic  affections.  In  angina  parenchymatosa,  if  sup- 
puration is  inevitable,  it  should  be  hastened  by  hot  applications  and  the 
abscess  opened  early.  Copious  irrigation  of  the  throat  with  warm  boric 
acid  solution  is  often  very  efficient.  Rest  in  bed,  liquid  diet,  plenty  of 
water.  Avoidance  of  transmission  of  the  disease.  (See  ''Diphtheria.") 
Pasteurization  of  milk  whenever  tonsillitis  appears  in  epidemic  form. 


296  DISEASES   OF    CHILDREN 

Hypertrophy  of  the  Tonsils 

Chronic  enlargement  of  the  tonsils  often  develops  after  repeated  at- 
tacks of  angina  or  pharyngitis,  not  rarely  follows  scarlatina  or  diph- 
theria, and  is  frequently  associated  with  adenoids.  When  the  tonsils 
become  so  large  as  to  obstruct  respiration,  the  same  symptom  com- 
plex makes  its  gradual  appearance  as  is  pathognomonic  of  adenoids 
with  which  it  is  ordinarily  associated.  As  in  the  latter  anomaly,  re- 
moval of  the  hypertrophied  tissue  is  the  only  actual  cure,  and  unless 
contraindicated  by  hemorrhagic  diathesis,  should  be  undertaken  as 
early  as  possible,  since  the  more  or  less  degenerated  tumors  act  not 
only  as  a  cause  of  a  number  of  reflex  phenomena  (e.g.,  enuresis),  but 
as  a  harboring  place  for  divers  pathogenic  bacteria,  including  the  tuber- 
cle bacillus.  As  is  well  known,  rheumatism  is  frequently  traceable  to 
infected  tonsils. 

Treatment. — Until  a  few  years  ago  tonsillotomy  was  looked  upon  as 
the  operation  of  choice.  Nowadays,  however,  tonsillectomy,  or  total 
enucleation  of  the  tonsils,  is  generally  preferred,  especially  if  the 
tonsils  are  submerged. 

Tonsillotomy. — This  is  usually  performed  in  the  following  manner : — 

The  patient  is  placed  on  a  table  (if  an  anesthetic  is  to  be  used),  or 
seated  on  a  lap  of  an  assistant  or  nurse.  The  arms  are  immovably  fixed 
by  means  of  a  wide  towel  or  sheet.  The  tonsillotome  is  introduced 
into  the  mouth  like  a  tongue  depressor  and  turned  sideways  and 
pressed  against  the  base  of  the  hypertrophied  tonsil  so  that  its  sum- 
mit protrudes  through  the  circular  opening  of  the  tonsillotome.  With 
the  tonsillotome  thus  fixed  and  the  thumb  of  the  operator  in  the 
handle  of  the  blade,  the  latter  is  firmly  driven  through  the  gland. 

The  same  procedures  are  repeated  for  the  other  tonsil. 

Tonsillectomy  or  Enucleation  of  Tonsils. — The  patient  is  fully  anes- 
thetized, the  mouth  widely  separated  with  a  mouthgag,  and  the  field 
of  operation  highly  illuminated.  The  right  tonsil  is  grasped  with 
long  but  fine  tooth  forceps,  and  beginning  with  the  anterior  superior 
portion  of  the  tonsil  and  pillar,  the  tonsil  is  gently  loosened  from  its 
attachments,  by  means  of  a  right  angled  dissecting  knife.  The  enu- 
cleated tonsil  is  then  put  on  a  stretch  and  severed  from  the  adherent 
constrictor  by  means  of  a  cold  wire  snare.  The  field  of  operation  is 
kept  free  from  blood  and  mucus  by  the  suction  apparatus.  The  same 
procedures  are  followed  for  removal  of  the  left  tonsil.  Some  surgeons 
recommend  the  application  of  a  tonsil  hemostat  to  prevent  sudden 
hemorrhage.  The  patient  is  not  allowed  to  leave  the  table  until  the 
throat  is  perfectly  dry.    Tonsillectomy  is  a  more  or  less  capital  opera- 


DISEASES    OF    THE   RESPIRATORY    SYSTEM 


297 


tion,  and  calls  for  all  the  precautions,  as  regards  preparation  and  after 
treatment,  as  do  other  serious  operations. 

Postoperative  Hemorrhage. — Slight  bleeding  requires  no  special 
treatment  except  ice-collar  to  the  neck.  Profuse  hemorrhage  should  be 
promptly  checked  by  tonsil  hemostats,  adrenalin  and  thromboplastin 
locally,  and  by  all  other  therapeutic  measures  generally  employed  in 
severe  hemorrhage.  (See  "Dangers  and  Accidents  Attending  Adenoid 
Operation,"  p.  300.) 

Adenoid  Vegetations 

(Hypertrophy  of  the  Nasopharyngeal  or  Luschka's  Tonsil) 

The  mucous  membrane  of  the  rhinopharynx  is  normally  rich  in  lym- 
phoid or  adenoid  tissue  which  bears  the  name  of  nasopharyngeal  or 
Luschka's  tonsil.     Like  the  faucial  tonsils,  the  latter  is  subject  to  f re- 


Fig.  70. — Adenoids  in  a  boy  eleven  years  old.     Note  characteristic,  dull,  facial  fea- 
tures and  contracted  chest. 

quent  attacks  of  inflammation  with  secondary  hypertrophy.  Whenever 
the  hypertrophied  adenoid  tissue  assumes  such  proportions  as  to  more 
or  less  fill  the  nasopharyngeal  space  and  obstruct  nasal  breathing,  a 
pathognomonic  clinical  syndrome  develops  which,  though  apparently 
insignificant  in  its  lesion,  is  often  very  verious  in  its  immediate  and 
remote  consequences. 


298 


DISEASES  OF   CHILDREN 


The  clinical  picture  unfolds  gradually,  almost  insidiously,  growing 
more  pronounced  from  time  to  time  as  the  patient  "catches  cold."  The 
child  is  unable  to  clear  the  nasopharynx,  and  the  retained  irritating 
nasal  discharge  helps  to  swell  the  adenoid  tissue  and  to  obstruct  the 
rhinopharynx.  He  is  thus  forced  to  breathe  through  the  mouth.  As 
immediate  results,  we  find  that  he  constantly  keeps  his  mouth  open,  es- 
pecialh'  during  sleep,  which  is  greatly  disturbed,  and,  as  a  rule,  he 
snores  heavily.  As  the  nasal  obstruction  increases,  he  is  frequently 
awakened  by  extreme  dryness  of  the  throat,  and  a  croupy  harassing 


Fig.  71. — Spinal  curvature   (stooping)   secondary  to  adenoids. 

cough.  In  the  morning  he  is  tired,  complains  of  headache,  is  drowsy  and 
apathetic.  His  speech  is  dull,  nasal  {m  and  n  sound  like  b  and  d),  hesi- 
tating, and  sometimes  stuttering.* 

If  it  were  possible  to  bring  these  little  sufferers  under  proper  treat- 
ment at  this  stage  of  the  disease,  quick  and  uneventful  recovery  would 
be  the  rule.  Unfortunately,  however,  the  laity,  nay,  the  physicians  as 
well,  rarely  think  these  sj^mptoms  of  sufficient  gravity  to  necessitate 


*It  should  be  remembered,  however,  that  the  presence  of  adenoids  does  not  necessarily  pro- 
duce the  typical  symptoms  of  the  disease.  It  all  depends  upon  the  proportionate  size  of  the  tumor 
to  that  of  rhinopharynx. 


DISEASES    OP    THE    RESPIRATORY    SYSTEM  299 

medical  and  particularly  surgical  intervention.  The  deplorable  con- 
dition is  therefore  allowed  to  proceed  and  the  tumor  to  spread  and 
sprout.  The  sequehe  appear  in  rapid  succession.  The  labored  breath- 
ing sooner  or  later  produces  deformity  of  the  thorax  (pigeon  breast) 
and  often  curvature  of  the  spine.  Owing  to  nonparticipation  of  the 
nose  in  respiration  there  is  gradual  atrophy  of  the  levators  alffi  nasi 
et  labii  superiores,  the  depre>ssors  alae  nasi,  and  the  septum  mobile.  The 
nose  becomes  pinched  and  pointed,  the  external  angle  of  the  eye  deeper 
than  the  internal,  the  lower  lid  droops,  the  lower  jaw  sinks  down,  and 
the  face  assumes  that  dull,  fixed  and  irresolute  expression  which  is  so 
characteristic  of  adenoids.  In  addition  to  this,  hearing  is  impaired  as 
a  result  of  secondary  catarrhal  inflammation  of  the  Eustachian  tube,  etc. 
The  child  is  absent-minded  and  dull  of  perception,  does  poorly  at  school, 
and  becomes  the  target  for  abuse  and  corporal  punishment  by  teachers 
and  parents — all  for  no  fault  of  liis.  When  brought  to  the  physician — 
often  chiefly  on  account  of  impaired  hearing — the  diagnosis  can  readily 
be  made  by  mere  inspection.  Such  a  superflcial  examination,  however, 
should  not  be  relied  on,  as  similar  symptoms  are  produced  by  nasal  ob- 
struction from  other  causes  (deformities,  growths,  foreign  bodies,  etc.). 
Inspection  of  the  mouth  reveals  the  bony  palate  high  and  narrow,  leav- 
ing insuflicient  space  for  the  teeth  and  causing  their  displacement. 
The  faucial  tonsils  are  greatly  enlarged  (in  about  25  per  cent  of  the 
eases),  the  posterior  pharyngeal  wall  is  granular,  and,  with  the  velum 
palati  raised,  often  shows  the  distal  ends  of  the  adenoid  vegetation. 
Rhinoscopy  confirms  the  presence  in  the  nasopharyngeal  space  of  a  pale- 
red,  smooth,  soft  tumor  which  sometimes  resembles  a  mass  of  earth- 
worms. It  bleeds  readily.  The  diagnosis  is  further  corroborated  by 
palpating  with  the  finger  the  soft  masses  blocking  the  rhinopharynx, 
or  by  nipping  off  a  small  portion  of  the  adenoid  vegetations  by  means 
of  adenoid  forceps  introduced  behind  the  velum  palati. 

Treatment. — The  diagnosis  once  established,  the  treatment  should 
be  prompt  and  energetic.  Mild  cases  hi  their  early  stages  may  be  ar- 
rested at  their  inception  by  scrupulous  cleanliness  of  the  nasopharynx, 
local  applications  of  Lugol's  solution  or  2  per  cent  nitrate  of  silver,  or 
5  to  10  per  cent  argyrol,  silvol  or  solargentum,  change  of  air,  outdoor 
exercise,  cold  shower  baths,  and  hematinics  and  alteratives  internally. 
These  procedures  should  also  be  followed  in  cases  with  Jiernorrhagic  diath- 
esis where  an  operation  is  contraindicated  for  fear  of  uncontrollable 
bleeding,  and  in  those  associated  with  other  grave  affections,  e.  g.,  acute 
or  subacute  endocarditis.  In  all  other  cases,  removal  of  the  adenoids  is 
the  only  actual  cure,  and  should  be  undertaken  as  early  as  possible. 
The  mode  of  procedure  varies  with  each  individual  case.     In  young 


300  DISEASES    OF    CHILDREN 

children  iiiuler  three  years  of  age,  the  operation  may  be  performed  with- 
out (preferably  with  !)  an  anesthetic,  in  the  sitting  posture ;  in  older  ones 
or  in  those  who  are  hypersensitive  to  pain  and  shock,  under  primary 
anesthesia  with  ether  (drop  by  drop  method),  ethyl  chloride  or  bromide 
or  nitrous  oxide  gas,  in  the  recumbent  posture.  The  child's  arms  are 
fastened  to  the  sides  of  the  thorax  by  a  wide  towel,  and  his  jaws  are 
separated  by  a  mouth  gag  placed  between  the  left  upper  and  lower  teeth. 
The  operator  stands  on  the  right  side  of  the  patient  and  introduces  the 
adenoid  curette  sideways  into  the  latter 's  mouth  and  passes  it  beneath 
the  soft  palate  and  up  along  the  anterior  wall  until  he  reaches  the  vault 
of  the  rhinopharynx.  The  physician  then  implants  the  cutting  edge  of 
the  instrument  into  the  adenoid  mass  and  makes  a  firm  semicircular 
movement,  directed  backward,  downward  and  forward.  One  such  move- 
ment usually  suffices  to  remove  the  tumor.  It  may  be  followed,  however, 
by  a  few  light,  similar  strokes,  to  smoothen  the  rough  edges.  The  pa- 
tient is  then  turned  on  the  side  to  allow  the  blood  to  drain  into  a  basin. 
This  may  be  facilitated  by  the  injection  of  ice-cold  water  through  the 
nostrils.  After  arresting  the  more  or  less  profuse  hemorrhage,  which 
always  accompanies  the  operation,  the  child  is  put  to  bed  for  a  few 
hours  until  he  has  regained  full  consciousness  and  is  kept  indoors  for  a 
day  or  two  on  a  nonirritating,  cool,  liquid  diet. 

After-Treatment. — To  prevent  the  recurrence  of  the  adenoids,  which 
is  prone  to  take  place  in  children  with  a  tendency  toward  glandular 
hyperplasia,  it  is  advantageous  to  instill  into  each  nostril  a  few  drops 
of  Lugol's  solution,  once  every  other  day  for  a  period  of  about  four 
weeks,  and  to  use  an  oily  antiseptic  spray  for  several  weeks  thereafter. 
This  procedure  will  prevent  also  adhesions  between  the  cut  surfaces 
and  the  soft  palate.  Delicate  children  should  be  put  on  syrup  of  the 
iodide  of  iron,  cod  liver  oil,  etc.  To  regulate  nasal  breathing,  it  is  of- 
ten necessary  by  means  of  a  bandage  to  keep  the  mouth  closed,  espe- 
cially at  night,  and  to  have  the  child  take  prolonged  breathing  exer- 
cises with  closed  mouth.  Impaired  speech  sometimes  calls  for  instruc- 
tion in  speaking  or,  in  the  event  of  a  paretic  condition  of  the  velum 
palati  arising  from  inactivity,  for  treatment  by  electricity  and  tonics. 
In  the  majority  of  instances,  however,  the  operation  is  followed  by 
immediate  restitutio  ad  integrum.  All  reflex  symptoms  and,  to  a  great 
extent,  even  the  deformities  of  the  thorax  subside  rapidly. 

Dangers  and  Accidents  Attending  Adenoid  and  Tonsil  Operations 

Simple  and  harmless  as  the  operation  is  under  ordinary  conditions, 
it  is  not  always  free  from  danger.  As  in  more  serious  operations,  the 
possibility  of  fatality  from  the  effect  of  the  anesthetic  or  infection  is 


DISEASES    OP    THE    RESPIRATORY    SYSTEM  :  '  ■      '  ?X)\ 

gravel}-  to  be  borne  in  mind,  and  the  frequency  of  primary  or  secondary 
• — oecasionall}-  fatal — hemorrhage  should  engage'  the  constant  atten- 
tion of  the  operator.  Hence  the  importance  also  of  testing  the  coag- 
ulability^ of  the  patient's  blood  before  the  operation. 

To  obviate  untoward  complications  all  such  preparations  should  be 
made  as  are  customary  Avith  capital  operative  work.  Ethyl  chloride 
and  ether  (drop  by  drop  method)  should  be  the  anesthetic  of  choice, 
and  primary  in  preference  to  deep  anesthesia.  The  instruments  to 
be  used  should  be  carefully  sterilized,  and  the  field  of  operation  and 
everything  coming  in  contact  with  it  rendered  as  aseptic  as  possible. 
Before  beginning  the  operation,  the  surgeon  should  test  the  efficiency 
and  entirety  of  his  instruments,  and  see  to  it  that  he  is  amply  sup- 
plied with  all  such  drugs  (peroxide  of  hydrogen,  suprarenal  gland 
in  solution  1:1000,  thromboplastin,  the  tincture  of  chloride  of  iron, 
etc.),  and  with  implements  (postnasal  tampon,  artery  forceps,  sponge 
holder  and  styptic  gauze — which  can  be  used  to  exert  direct  pressure 
upon  the  bleeding  spot;  actual  cautery,  etc.),  as  will  enable  him 
promptly  to  check  profuse  hemorrhage.  Postoperative  fever  is  generally 
due  to  some  form  of  throat  infection  and  hence  should  promptly  be 
treated  by  local  application  of  tincture  of  iodine  or  argyrol  (25  per  cent 
solution). 

Retropharyngeal  Abscess 
(Retropharyngeal  Lymphadenitis) 

Retropharyngeal  abscess  is  a  disease  of  early  infancy  and  childhood 
when  the  retropharyngeal  lymph  nodes  are  in  a  state  of  highest  develop- 
ment. It  usually  begins  as  retropharyngeal  lymphadenitis,  most  fre- 
quently the  result  of  infection  by  offensive  nasopharyngeal  discharges. 
More  rarely  it  is  due  to  spondylitis  of  the  cervical  vertebrae,  or  occurs 
as  a  metastatic  abscess,  or  in  consequence  of  trauma.  Not  all  cases  of 
lymphadenitis  undergo  suppuration;  on  the  contrary,  quite  a  number 
retrogress  and  escape  attention.  Hence  the  apparent  rarity  of  retro- 
pharyngeal disease.  Some  cases  undergo  suppuration  and  break  spon- 
taneously, and  others  run  a  rather  latent  course,  and  when  seen  by 
the  physician  present  fully  developed  abscesses.  Digital  examination 
of  the  throat  usually  reveals,  at  a  late  stage,  a  round  or  oval  fluctuating 
mass  the  size  of  a  pigeon's  egg,  in  the  median  line  of  the  pharynx,  and 
more  rarely,  laterally  on  a  line  with  the  velum  palati  or  somewhat  be- 
low it.  In  the  more  advanced  stages  the  abscess  may  be  recognized  as 
a  bluish-red  tumor  on  ordinary  inspection  of  the  pharynx. 

The  symptoms  vary  with  the  size  of  the  tumor.  In  marked  cases  they 
consist  of  dysphagia,  snoring  respiration,  especially  during  sleep,  muffled 


DISEASES   OF    CHILDREN 


voice  "aiid  -i^h'tlr^rdgf e^^ve  growth  of  tlic  swelling,  dyspnea  and  attacks 
of  asphyxia  J  "VViter^  deglutition  is  very  painfvil  there  is  also  sympa- 
thetic pseudotorticollis.  Occasionallj'  the  submaxillary,  parotid  and 
other  neighboring  glands  are  involved;  and  in  spontaneous  rupture  of 
the  abscess  metastatic  abscesses  are  apt  to  develop  in  the  ear  and  the 
supraclavicular  fossa,  mediastinum,  and  lungs.  The  temperature  is  usu- 
ally high  in  the  early  stage  of  the  disease,  and  remittent  later. 

Treatment. — Early  opening  of  the  abscess  is  therefore  imperative. 
This  is  best  accomplished  by  gently  perforating  it  by  means  of  a 
pointed  artery  clamp  and  widening  the  puncture  by  opening  the  clamp. 


Fig.  72. — Eetropharyngeal  abscess  in  a  ten-month-old  infant.     Note  characteristic  at- 
titude of  mouth,  head  and  neck. 


Before  opening  the  abscess  the  child's  head  is  held  upright  and  stead- 
ied from  behind  by  an  assistant.  As  soon  as  the  perforation  is  made, 
the  child's  head  should  be  promptly  bent  forward  to  prevent  the  pus 
from  entering  the  larynx  (danger  of  asphyxia,  aspiration  pneumonia, 
etc.)  and  the  nose  and  throat  cleared  of  blood,  pus  and  mucus. 

In  multiple  communicating  abscesses  with  palpable  involvement 
of  the  adjacent  gland,  the  operation  is  preferably  performed  (with  a 
knife)  from  the  outside,  so  as  to  afford  thorough  drainage.  Sometimes 
it  is  of  advantage  to  poultice  the  abscess  for  a  few  days  before  open- 
ing it. 


DISEASES    OF    THE    RESPIRATORY    SYSTEM  303 

Relief  fi-om  the  symptonis  is  vei-y  ])rompt  after  evacuation  of  the 
pus.  Rapid  recovery,  liowever,  occurs  only  in  primary  streptococcic 
or  staphylococcic  abscesses.  In  metastatic  and  tuberculous  abscesses 
(especially  the  latter)  the  disease  proceeds  a  protracted  course,  the 
prognosis  depending  upon  the  original  disease  and  the  age  and  vitality 
of  the  patient.     CTcneral  attention  to  the  nasopharynx.     Ilematinics. 

Otitis  Media 

(Otitis  Externa,  Furitnculosis,  Foreign  Bodies  in  the  Ear, 

Mastoiditis) 

The  gravest  feature  of  nasopharyngeal  affections,  be  they  primary  or 
secondary,  is  their  great  tendency  to  ear  complications.  The  naso- 
pharynx and  ear  being  in  direct  communication  through  the  Eustachian 
tube,  infectious  material  can  readily  travel  from  the  nose  and  throat 
to  the  middle  ear  and  transfer  the  disease  from  one  locality  to  the  other. 
Hence  the  frequency  of  ear  disease  in  rhinitis,  adenoids,  divers  exan- 
thematous  affections,  influenza,  etc.  Only  a  small  percentage  of  cases  of 
otitis  media  are  contracted  through  traumatism,  sea  bathing,  or  ex- 
tension of  an  inflammation  from  the  external  auditory  meatus;  and,  in 
infants,  middle-ear  disease  with  masked  symptoms  is  occasionally  ob- 
served in  connection  with  wasting  diseases  (e.  g.,  tuberculosis,  marasmus, 
syphilis).     Epidemics  of  ear  disease  are  not  rare. 

The  infection  may  remain  limited  to  the  Eustachian  tube  {catarrh  of 
the  Eustachian  canal),  and  give  rise  to  very  few  and  mild  symptoms. 
The  child  may  complain  of  earache  for  a  day  or  two,  perhaps,  wake 
up  at  night  with  a  crying  spell,  but  get  immediate  and  usually  perma- 
nent relief  after  application  of  heat  or  some  "ear  drops."  Sometimes 
the  pain  may  return  and  get  much  more  intense,  and  examination  of 
the  drum  would  show  injection  of  the  drum  or,  perhaps,  a  slight  muco- 
purulent discharge  indicating  spontaneous  rupture  of  the  membrane. 
The  discharge  may  continue  for  a  few  days  or  weeks  and  disappear 
without  further  ado.  In  another  group  of  cases,  due  to  greater  virulence 
of  the  infective  material  or,  possibly,  neglect,  the  inflammatory  process 
pursues  a  more  violent  course  {otitis  media,  purulenta) .  The  tempera- 
ture rises,  the  earache  is  very  intense,  (but  may  be  absent!),  the  child  is 
very  restless,  cries  almost  incessantly,  rubs  or  strikes  the  ear  with  its 
hands,  and,  as  the  symptoms  persist,  there  may  be  vomiting  and  cere- 
bral irritation  up  to  convulsions.  If  the  pus  is  not  evacuated,  we  soon 
find  that  it  eats  its  way  into  the  deeper  structures,  leading  either  to  an 
acute  or  chronic  involvement  of  the  bone  {mastoiditis).  In  severe  in- 
fections this  stage  of  the  disease  is  often  reached  within  a  few  days.    The 


304  DISEASES   OP   CHILDREN 

aforementioned  constitutional  symptoms  are  greatly  exaggerated.  The 
local  signs — in  addition  to  intense  earache,  deafness,  headache  and 
marked  congestion  of  the  drum — are  also  augmented  by  tenderness  over 
the  mastoid  process  and  by  edema  of  the  tissues  covering  the  bone,  ex- 
tending downward  along  the  entire  side  of  the  neck  and  backward  to  the 
retromaxillary  fossa,  pushing  the  auricle  forward.  The  upper  and 
lower  walls  of  the  meatus  are  more  or  less  swollen  and  the  drum  is  highly 
inflamed,  bulging  and  irregular  in  contour,  while  the  posterior  supe- 
rior quadrant  of  the  drum  with  the  adjacent  wall  of  the  canal  is  sag- 
ging. The  further  course  of  the  affection  depends  greatly  upon  the  mode 
of  treatment.  If  the  inflammatory  process  is  allowed  to  continue,  the  pus 
may  find  its  way  either  externally,  somewhere  along  the  side  of  the  neck, 
into  the  throat  (retropharyngeal  abscess),  or,  in  malignant  cases,  into 
the  lateral  sinus  (pJilehitis,  thrcmibosis)  or  the  middle  fossa  of  the  skull 
{meningitis,  purulent  encephalitis).  The  same  grave  condition  is  some- 
times observed  in  otitis  pursuing  a  very  slow  course — months  or  years. 
In  these  cases  it  is  usually  found  that  the  patient  is  suffering  from  re- 
current attacks  of  earache  with  or  without  profuse  purulent  discharge, 
more  or  less  severe  headache,  dizziness,  occasional  rise  of  temperature, 
tenderness  over  the  mastoid  process,  and,  toward  the  end,  loss  of  weight, 
anorexia,  persistent  headache  and  repeated  vomiting. 

The  disease  having  reached  this  deplorable  stage,  one  is  very  rarely 
apt  to  err  in  the  diagnosis.  A  question  may  arise  as  to  whether  the 
meningeal  symptoms  are  secondary  to  otitis  or  to  some  other  affection 
(e.g.,  pneumonia,  sepsis),  or  primary  in  character.  A  history  of  ear 
disease  and  the  presence  of  local  ear  symptoms  (discharge,  inflammation 
of  the  drum,  etc.)  at  once  point  to  its  true  nature.  Nor  is  there  any 
difficulty  in  diagnosing  otitis  media  purulenta  with  acute  symptoms. 
The  diagnosis,  however,  is  not  so  easy  in  cases  with  an  insidious  course. 
It  is  especially  difficult  when  the  ear  symptoms  are  masked  by  mani- 
festations of  the  primary  affection  {e.g.,  influenza),  but  an  electro- 
otoscopie  examination  almost  invariably  clears  up  the  diagnosis,  and 
should  always  be  resorted  to  whenever  inexplicable  pain  or  tempera- 
ture prevails.  In  fact,  no  examination  of  a  baby  is  complete  without 
such  an  examination.  Only  very  recently  I  had  occasion  to  find  double 
otitis  in  a  boy  fourteen  months  old  who,  for  three  weeks,  was  treated 
by  a  prominent  clinician  for  "central  pneumonia."  Mild  cases  of  middle 
ear  disease  may  be  mistaken  for  otitis  externa.  In  this  affection,  how- 
ever, the  local  signs  are  limited  to  the  external  auditory  canal  (redness 
and  narrowing  of  the  meatus  without  involvement  of  the  drum).  Simi- 
larly, middle  ear  disease  may  be  confounded  with  fiirunculosis  or  foreign 
bodies  in  the  auditory  meatus,  but  these  can  readily  be  eliminated  by 


DISEASES   OP    THE    RESPIRATORY    SYSTEM  305 

an  otoscopic  examination  showinp;-  tlie  seat  of  the  lesion.  Occasionally 
an  abscess  in  the  external  canal  burrowing  itself  through  the  cartilagi- 
nous portion  of  the  canal  in  back  of  the  ear  may  be  mistaken  for  mastoid 
abscess;  in  such  cases  constitutional  symptoms  and  inflammation  of  the 
drum  are  absent  and  the  abscess  is  superficial  and  communicating  with 
the  swelling  in  the  external  canal. 

Treatment. — Bearing  in  mind  the  great  tendency  of  nasopharyn- 
geal affections  to  lead  to  ear  disease,  and  the  latter  to  become  a  source 
of  everlasting  misery  and  death,  it  is  self-evident  that  all  precautions 
should  be  taken  to  prevent  the  causes  and  their  dreadful  results.  Dur- 
ing the  course  of  acute  febrile,  especially  exanthematous  diseases, 
the  nasopharynx  should  receive  especial  attention  in  the  way  of  care- 
ful, gentle  cleansing.  Warm  salt  water  or  albolene,  or  some  silver 
preparation  should  be  instilled  into  the  nose  twice  daily,  preferably 
with  a  spoon  or  dropper,  lest  forcible  syringing  may  drive  the  dis- 
charge from  the  nasopharynx  into  the  Eustachian  tube.  Hypertrophied 
tonsils  and  adenoids  should  be  removed  (during  the  quiescent  stage 
of  the  otitis!)  and  chronic  nasopharyngeal  catarrh  treated  with  ap- 
propriate remedies.  The  instillations  should  also  be  continued  after 
the  appearance  of  ear  symptoms,  and  as  long  as  the  membrane  is  in- 
tact syringing  of  the  ear  with  warm  boracic  acid  solution  will  prove 
beneficial.  If  the  otitis  continues  and  the  drum  does  not  rupture 
spontaneously,  free  paracentesis,  preferably  under  primary  anesthesia, 
should  be  performed  without  delay,  to  allow  the  pus  to  escape.  The 
mode  of  after-treatment  is  still  subject  to  controvery,  several  prom- 
inent otologists  preferring  the  "dry"  method  (drying  of  the  external 
auditory  canal  several  times  a  day  and  loosely  draining  with  absorbent 
gauze)  to  repeated  syringing.  Some  otologists  recommend  to  cleanse 
the  ear  once  a  day  by  suction  and  to  follow  it  up  with  packing.  Where 
the  discharge  continues,  instillation  of  a  few  drops  of  a  2  per  cent 
solution  of  nitrate  of  silver,  or  in  very  chronic  cases  cauterization 
of  the  tympanum  with  trichloracetic  acid  will  be  found  to  act  splen- 
didly. If  sensitiveness  over  the  mastoid  is  detected  and  the  consti- 
tutional symptoms  show  that  the  disease  is  rapidly  growing  worse,  an 
attempt  should  be  made  to  arrest  its  progress  by  a  new  paracentesis, 
ice  bags  and  leeches  and,  if  improvement  does  not  set  in  early,  there 
is  nothing  else  left  but  immediately  to  proceed  with  opening  of  the 
mastoid  process  with  a  chisel  to  prevent  the  pus  invading  the  sinus, 
meninges  or  brain  substance.  In  the  majority  of  instances  a  radical 
mastoid  operation  is  a  life-saving  procedure.  Unfortunately,  this 
operation  is  not  rarely  undertaken  either  too  late  or  on  a  patient  in 
a  state  of  very  low  vitality  from  the  baneful  effect  of  the  primary 


Aeidi  Phenolis                                            gr  v 

0.333 

Mentholis                                                    gr  ii 

0.133 

Glycerin!                                                    3  iv 

15.00 

M. 

S. — "Ear  drops,"  in  acute  eases. 

Hydrargyri  Cliloridi  Corrossivi          gr  ss 

0.003 

Aleoholis                                                   3  iv 

15.00 

M. 

S. — "Ear  drops,"  in  chronic  cases. 

306  DISEASES    OF    CHILDREN 

disease,  so  that  the  results  are  not  always  very  gratifying.  It  is 
questionable  whether  operative  interference  is  to  be  advised  after  the 
disease  has  spread  to  the  meninges  or  brain.  The  recoveries  in  these 
cases  are  certainly  very  few  and  far  between. 

Pain  should  be  relieved  by  small  doses  of  codeine,  and  other  symp- 
toms arising  should  be  met  in  accordance  with  indications.  Change 
of  air  often  works  wonders  in  recalcitrant  cases. 


IJ 


Deafness 

From  a  study  of  1,076  congenitally  deaf  children,  Yearsley  reports 
heredity  and  consanguinity  to  be  the  most  important  factors;  with  al- 
coholism, insanity,  and  syphilis  the  most  important  minor  causes.  Of 
592  cases  of  acquired  deaf-mutism  72.2  per  cent  were  due  to  suppura- 
tive or  catarrhal  middle  ear  disease,  in  which  infectious  fevers  and 
adenoids  played  an  important  part.  Statistics  collected  by  other 
clinicians  show  similar  data  regarding  the  etiologic  factors  of  deaf- 
ness. 

Testing  the  Hearing. — The  acuteness  of  hearing  is  determined  by 
the  watch  test  and  the  voice  test  applied  separately  to  each  ear.  Dur- 
ing both  the  watch  and  the  voice  tests,  the  eyes  of  the  patient  should  be 
closed,  in  order  that  lip  reading  may  not  be  possible,  and  that  the 
distance  of  the  watch  or  the  speaker  may  not  influence  the  patient.  In 
tests  relative  to  differential  diagnosis  and  prognosis  the  tuning  fork 
is  used. 

Weber's  Test. — In  this  test  a  Cg  tuning  fork,  having  512  vibrations 
per  second,  is  vibrated  and  the  handle  placed  against  the  upper  central 
incisor  teeth  or  upon  the  middle  line  of  the  cranium.  If  the  sound  is 
heard  better  in  the  afflicted  ear  it  is  indicative  of  some  affection  of  the 
conducting  apparatus,  such  as  middle  ear  disease,  impacted  cerumen 
in  the  external  auditory  canal,  or  occlusion  of  the  Eustachian  tube; 
while  if  heard  better  in  the  normal  or  less  afflicted  ear,  it  is  the  per- 
ceptive, or  nerve,  apparatus  that  is  at  fault. 

Rinne's  Test. — This  test  depends  upon  the  fact  that  the  normal  ear 


DISEASES   OP   THE   RESPIRATORY   SYSTEM  307 

is  more  sensitive  to  sounds  transmitted  through  the  air  than  to  those 
transmitted  by  the  bony  framework  of  the  ear.  In  a  normal  ear, 
if  the  handle  of  a  vibrating  C,  (512  vibrations)  tuning  fork  is  held 
against  the  mastoid  until  the  patient  no  longer  hears  any  sound,  and 
then  the  free  tips  of  the  fork  be  brought  close  to  the  external  ear,  the 
sound  will  be  heard  again.  This  is  knoAvn  as  positive  Rinne.  If,  how- 
ever, the  sound  is  not  heard  again  when  the  fork  is  thus  transposed,  it 
is  known  as  negative  Rinne.  In  a  defective  ear,  a  negative  Rinne  test 
shows  a  relative  reduction  of  aerial  conduction  or  a  similar  increase  in 
bone  conduction  and  indicates  obstruction  or  disease  of  the  normal  con- 
ducting apparatus;  while  a  positive  Rinne  test,  in  a  defective  ear,  is  an 
indication  of  a  lesion  in  the  perceptive  apparatus  of  the  internal  ear. 

Schwabach's  Test. — This  test  depends  upon  the  fact  that  in  middle 
ear  disease,  a  fork  vibrating  in  contact  with  the  cranium  is  heard  longer 
in  an  affected  than  in  a  normal  ear.  When  the  auditory  nerve  is  af- 
fected, it  is  heard  longer  by  the  normal  ear.  The  fork  is  struck  and 
placed  on  the  patient's  mastoid  and  when  the  patient  ceases  to  perceive 
the  sound,  the  fork  is  transferred  to  the  examiner's  mastoid.  If  still 
heard  by  the  normal  ear  of  the  examiner,  it  indicates  labyrinthine  dis- 
ease in  the  patient.  If  not  heard,  the  test  is  reversed,  the  examiner  first 
placing  the  vibrating  fork  on  his  own  mastoid,  and,  when  the  sound  has 
died  away,  transfers  it  at  once  to  the  patient's.  If  heard  by  the  patient 
after  the  examiner's  normal  ear  has  ceased  to  hear  it,  an  obstruction 
of  sound  condition,  but  not  disease  of  the  nerve,  is  indicated. 

Interpretation  of  Above  Tests 

A  negative  Rinne  test  indicates  middle  ear  disease  which  should 
be  partly  or  entirely  benefited  by  treatment.  A  positive  Rinne  test 
indicates  nerve  deafness  which,  with  a  few  exceptions,  implies  an 
unfavorable  prognosis.  The  Schwabach  test  deduces  an  abnormal  con- 
dition of  the  conducting  apparatus  (middle  ear)  when  bone  conduction 
is  lengthened  and,  conversely,  disturbance  of  the  nervous  mechanism 
when  bone  conduction  is  impaired.  The  Weber  test  is  only  valuable 
in  indicating  disease  of  the  perceptive  apparatus  in  unilateral  deafness, 
when  the  sound  is  accentuated  in  the  normal  ear;  the  chief  objection 
to  the  test  being  the  uncertainty  of  the  localization  of  the  auditory 
perception  in  one  ear.  Tuning-fork  tests  are  said  to  be  of  value  as  aids 
to  prognosis  when  they  point  to  middle  ear  disease.  However,  the  deduc- 
tions drawn  from  these  tests  should  be  used  with  caution  as  the  pitch 


308  DISEASES   OF   CHILDREN 

and  intensity  of  the  sounds  employed  may  sometimes  cause  them  to 
vary  and  even  to  be  the  direct  opposite  of  what  the  formulated  rules 
would  lead  us  to  expect.  Even  with  indications  of  a  diseased  percep- 
tive apparatus,  supported  by  many  tests,  an  unfavorable  prognosis 
should  be  withheld  until  treatment  has  been  administered  and  found 
unavailing. 

Indications  of  Labyrinth  or  Auditory  Nerve  Deafness 

1,  When  the  tuning  fork  is  heard  better  through  the  air. 

2.  When  the  power  of  hearing  is  better  in  a  quiet  place. 

3,  When  noises  are  markedly  annoying. 

4.  When  inflation  of  the  middle  ear  makes  the  hearing  worse. 

Among  the  various  tests  employed  in  the  diagnosis  of  labyrinthine 
disease  that  of  Barany  is  without  danger  and  may  prove  of  service. 
According  to  Barany,  when  the  vestibule  is  healthy,  the  injection  of 
water  at  a  temperature  of,  say  80°  F.  into  the  external  auditory  canal 
will  develop  a  circular  nystagmus  toward  the  opposite  side.  On  the 
other  hand,  if  the  temperature  of  the  water  be  above  that  of  the 
body,  the  nystagmus  will  be  toward  the  ear  syringed,  while  if  the 
labyrinth  be  destroyed  no  nystagmus  will  develop. 

Treatment. — Careful  attention  to  existing  external  and  middle  ear 
diseases.  Tonics  and  electric  vibration  may  prove  beneficial  in  laby- 
rinth deafness.  Iodides  and  mercury  are  always  worth  trying  even  if 
the  Wassermann  test  is  negative. 

Laryngitis  Acuta 

(Catarrhal  Laryngitis,  Spasmodic  or  False  Croup,  Laryngitis  Stri- 
DULA,  Membranous,  Nondiphtheritic  Croup) 

Acute  primary,  idiopathic  laryngitis  is  comparatively  rare  in  children, 
except  as  the  result  of  the  traumatic  action  of  strong  gases,  vapors, 
fluids  or  excessive  heat.  On  the  other  hand,  laryngitis  quite  frequently 
occurs  in  conjunction  with  divers  acute  exanthematous  diseases,  espe- 
cially measles  and  influenza,  often  follows  attacks  of  rhinitis,  pharyn- 
gitis, tonsillitis  and  esophagitis,  and  may  develop  in  connection  with 
intra-  and  extra-laryngeal  growths.  This  so-called  secondary  laryngitis 
affects  children  principally  of  from  two  to  ten  years  of  age. 

The  severity  of  the  symptoms  is  often  by  far  out  of  proportion  to 
that  of  the  underlying  anatomic  lesion.     Thus,  simple  hyperemia  of 


DISEASES   OF    THE   RESPIRATORY   SYSTEM  309 

only  a  small  portion  of  the  laryngeal  mucous  membrane  not  rarely  gives 
rise  to  marked  symptoms  of  suffocation. 

Several  forms  of  laryngitis  are  noted  in  practice : — 

1.  Catarrhal  Laryngitis. — The  child  complains  of  sore  throat  and 
sensitiveness  of  the  larynx  to  pressure.  The  cough  is  dry,  short,  and 
barking;  the  voice  husky  or  only  slightly  muffled.  Respiration  is  nor- 
mal ;  fever  is  absent  or  slight.  Expectoration  is  at  first  slight  and  of 
a  mucous  nature,  later  more  profuse  and  mucopurulent.  The  attack 
lasts  about  a  week. 

Occasionally,  especially  in  neglected  cases  or  in  those  suffering 
from  affections  of  the  nasopharynx,  the  laryngitis  may  pursue  a 
chronic  course  with  a  tendency  to  permanent  alteration  of  the  voice. 
In  this  event  laryngoscopic  examination  usually  reveals  a  moderate 
hyperemia  of  the  laryngeal  mucous  membrane,  and  in  some  cases  slight 
erosions. 

2.  Spasmodic  Laryngitis  (Laryngitis  Stridula,  False  Croup). — It 
develops,  either  very  suddenly  or  after  a  few  days'  illness,  with  ca- 
tarrhal laryngitis  or  nasopharyngitis.  Sudden  attacks  usually  occur 
in  children  under  eight  years  of  age,  more  frequently  in  boys  than 
in  girls.  After  retiring  apparently  healthy  and  sleeping  fairly  well 
until  about  midnight  (this  may  also  happen  during  the  day  after  pro- 
longed sleep,  when  the  nasopharyngeal  or  laryngeal  secretion  desiccates 
and  gives  rise  to  irritation  of  the  larynx,  and  possibly  edema  of  the  sub- 
chordal  tissue)  the  child  wakes  up  with  a  harsh,  croupy  cough,  inter- 
rupted by  deep  inspiratory  stridor.  The  child  looks  frightened  and  anx- 
iously gasps  for  air,  its  face  is  flushed  and  bathed  in  perspiration,  its  eyes 
stare  and  its  lips  are  cyanosed,  and  the  whole  clinical  picture  is  very 
alarming.  The  dyspnea  usually  passes  off  in  a  few  minutes,  but  may 
last  hours  with  slight  remissions  and  gradual  improvement.  Ordi- 
narily the  child  is  well  again  in  the  morning  except  for  a  simple  mild 
laryngitis  which  may  subside  in  two  to  ten  days  or  give  rise  to  re- 
newals of  the  attacks  for  a  few  successive  nights.  Sometimes  the 
paroxysm  may  be  so  severe  as  to  require  intubation  or  tracheotomy 
for  immediate  relief.  Spasmodic  croup  occasionally  forms  the  begin- 
ning of  pertussis,  measles,  influenza  or  membranous,  nondiphtheritie 
croup.    It  should  not  be  mistaken  for  spasmus  glottidis  (q.  v.). 

3.  Membranous,  Nondiphtheritie  Laryngitis. — In  the  beginning  the 
symptoms  are  those  of  simple  laryngitis.  Very  soon,  however,  the  ca- 
tarrh is  increased  in  intensity.  The  cough  becomes  harsher  and  more 
eroupy,  the  voice  hoarse  (sometimes  aphonia),  inspiration  prolonged 
and  expiration  noisy.     It  may  begin  also  with  bronchial  catarrh  and 


310  DISEASES   OF    CHILDREN 

become  suddenly  complicated  by  fibrinous  traelieolaryngitis — ascend- 
ing croup — reach  a  very  high  degree  of  intensity,  become  more  severe 
from  hour  to  hour,  and  threaten  suffocation,  if  not  immediately  relieved 
by  intubation  or  tracheotom}-.  Tlie  aspect  is  still  worse  when  the  croup- 
ous inflammation  descends  into  the  bronchi — bronchial  croup.  In  this 
condition  the  patient  may  cough  up  white  reticulated  shreds  (which 
float  in  water)  or  complete  cylinders  with  dichotomic  ramifications  or 
multiple  dendritic  branchings.  The  prognosis  in  such  cases  is  very 
grave.  The  pulse  fails,  the  dyspnea  and  cyanosis  increase,  the  patients 
fall  into  a  state  of  sopor  and  die  from  collapse.  Not  infrequently  fatal 
brain  symptoms  occur  as  a  result  of  passive  venous  congestion  in  the 
brain  and  transudation  in  the  ventricles.  The  course  and  termination 
of  the  disease,  how^ever,  is  not  always  so  bad,  and  quite  a  number  of 
uncomplicated  (sometimes  complicated  by  bronchopneumonia)  cases  re- 
cover without  much  ado. 

This  nondiphtheritic  form  of  laryngitis  is  often  mistaken  for  diph- 
theritic membranous  laryngitis,  but  a  diagnosis  can  in  the  majority  of 
cases  be  made  with  the  aid  of  the  following  differential  points : 

MEMBRANOUS   DIPHTHERITIC  MEMBRANOUS      NONDIPHTHERIT- 

LARYNGITIS  IC  LARYNGITIS 

Diphtheria   bacilli   present.  Absent.      Streptococci,    Stapliylococci    or 

Pneumococci  present. 

Distinctly  contagious,  giving  also  a  his-  Not  contagious. 

tory  of  contagion. 

Early   enlargement    of    the    submaxillary  Submaxillary  glands,   as   a  rule,  not  in- 

glands.  volved  or  slightly  so. 

Diphtheritic  patches  are  found,  as  a  rule.  The  fauces  may  be  covered  with  a  mucous 

on  the  fauces  and  posterior  pharyngeal  exudation,  which  can  easily  be  wiped 

wall.  off. 

Albuminuria  usually  present.  Absent. 

Treatment. — Mild  cases  do  nicely  on  very  simple  therapeutic  meas- 
ures, such  as  rest  in  bed,  attention  to  the  nasopharynx  (instillations  of 
warm  boracic  acid  solutions  several  times  daily;  occasionally  also 
5  per  cent  argyrol  or  silvol),  hot  baths,  hot  drinks  (tea,  lemonade, 
milk  and  seltzer,  Priessnitz's  compresses  or  turpentine  and  campho- 
rated oil  to  the  neck  and  a  few  doses  of  sodium  salicylate  internally 
to  relieve  the  sore  throat  and  to  stimulate  diaphoresis. 

Should  there  be  any  tendency  for  desiccation  of  the  laryngeal  se- 
cretion, softening  of  the  same  should  be  endeavored  by  means  of  ex- 
pectorants, steam  inhalations  and  emetics.  In  the  majority  of  instances 
this  mode  of  treatment  prevents  the  occurrence  of  attacks  of  spasmodic 
laryngitis. 


DISEASES   OP    THE   RESPIRATORY    SYSTEM  311 

I^     Villi   ipecaeliuanliEe    3  ss  2.00 

Syr.  scillsB  comp 3  i  4.00 

Syr.  senegae  3  ii  8.00 

Codeinae  sulpli gr  ss  0.033 

Ext.  glycyrrhizae  fl 3  ii  8.00 

Aquae   q.s.  ad  5  ii  60.00 

M. 

S. — One  teaspoonful  every  two  to  four  hours  for  a 

child  3  years  okl. 

I>     Eucalyptol    3i  4.00 

Tinct.  benzoiiii  comp 5  ii  60.00 

M. 

S. — One  teaspoonful  in  a  pint  of  hot  water  for  inhalation. 

Sudden  paroxysms  of  false  croup  are  best  remedied  by  ice  collar, 
prompt  emesis,  a  hot  mustard  bath  (see  p.  92),  a  large  dose  of  sodium 
bromide,  a  hypodermatic  injection  of  morphine  1/20  grain  and  atro- 
pine 1/400  grain,  counterirritation  by  a  strong  sinapism  and,  if  the 
cyanosis  increases  notwithstanding,  intubation  or  tracheotomy. 

The  management  of  membranous  nondiphtheritic  croup  is  frequently 
quite  a  difficult  proposition.  Hence,  the  importance  of  its  prevention 
by  early  attention  to  catarrhal  laryngitis.  Steam  inhalation  and 
emesis  are  useful  remedies,  and  inhalation  of  a  few  drops  of  chloro- 
form is  often  effective  to  relieve  threatening  dyspnea.  Severe  cases 
call  for  early  intubation  or  tracheotomy.  Eecurrent  laryngeal  spasm 
sometimes  yields  to  spraying  of  the  larynx  with  2  per  cent  solu- 
tion of  cocaine.  As  diphtheria  antitoxin  carefully  administered  is  a 
safe  remedy,  it  is  always  advisable  to  resort  to  it,  although  bac- 
teriologic  examination  of  the  pseudomembrane  fails  to  reveal  the  diph- 
theria bacillus.  Mixed  antistreptococcic,  staphylococcic  and  pneu- 
mococcic  sera  are  also  deserving  of  trial. 

Prophylaxis. — Removal  of  local  causes,  such  as  adenoids  and  large 
tonsils;  change  of  air;  tonics,  especially  cod  liver  oil. 

Laryngitis  Chronica 

Chronic  laryngitis  may  follow  repeated  attacks  of  acute  catarrhal  or 
diphtheritic  laryngitis  or  develop  slowly  by  extension  of  inflammation 
from  the  neighboring  structures.  Overexertion  of  the  voice  and  excessive 
smoking  in  boys  are  occasional  causes. 

Laryngoscopic  examination  shows  hyperemia  and  swelling  of  the 
mucous  membrane  of  the  larynx  which  vary  in  extent  Avith  the  duration 
of  the  affection.  The  mucous  membrane  is  sometimes  covered  with 
granulations,  and  in  severe  cases  shows  more  or  less  superficial  ul- 
ceration.    There  is  a  moderate  secretion  of  mucus  and  pus  which  has 


312 


DISEASES   OF    CHILDREN 


a  tendency  to  desiccate,  and  gives  the  sensation  of  a  foreign  body  in 
the  throat.  The  cough  is  usually  insignificant ;  occasionally,  however, 
troublesome,  harsh  and  barking,  especially  at  night. 

Diagnosis. — Although  syphilis  and  tuberculosis  of  the  throat  are 
comparatively  rare  in  children,  their  presence  should  always  be  sus- 
pected and  looked  for  in  obstinate  laryngitis.  The  following  differen- 
tial points  are  helpful  in  the  diagnosis: 


Simple  Laryn- 
gitis 

Syphilitic 

Tuberculous 

SECONDARY 

TERTIARY 

Lesion   

Hyperemia,     slight 

Mottled   hyper- 

Deep, angry  ul 

Anemia,     grayish 

thickening,     ero- 

emia,  super- 

cers,   cicatri- 

color, solid 

sion    of    mucous 

ficial  ulcera- 

ces, stenosis. 

thickening, 

membrane,    rare- 

tion. 

worm-eaten 

ly  slight  ulcera 

ulcers. 

tion. 

Expectoration 

Free  from  tubercle 

Spirochetes. 

The  same. 

Bacilli  present. 

bacilli. 

Deglutition  .  . 

Usually  painless. 

Normal. 

Difficult. 

Very  painful. 

Cough    

Dry  or  moist,  pain- 
less. 

Slight  hacking. 

Infrequent. 

Severe,  as  a  rule. 

Eespiration  . . 

Normal. 

Unaltered. 

Embarrassed 
with  stenosis. 

Early    accelera- 
tion. 

Voice 

Variable. 

Hoarse,  nasal. 

Raucous,  husky. 

Partial    or    com- 
plete aphonia. 

Complications 

Nasopharynx;  gen- 

Syphilitic 

The  same. 

Involvement  of 

eral  health  unaf- 

lesions   else- 

lungs,   emacia- 

fected. 

where. 

tion. 

Treatment. — Attention  to  existing  causes,  especially  adenoids  and 
enlarged  tonsils,  if  present;  local  application,  three  times  a  week,  of 
nitrate  of  silver  (1  per  cent  to  2  per  cent),  glycerate  of  tannin  (10 
per  cent),  or  chloride  of  zinc  (2  per  cent  to  4  per  cent)  ;  steam  inhala- 
tion (see  p.  311) ;  cleansing  of  the  nose  and  throat,  three  times  a  day, 
with  Dobell's  solution,  and  the  like,  will  very  promptly  effect  a  cure, 
provided  the  laryngeal  affection  is  not  based  on  some  grave  constitu- 
tional affection,  or  benign  (papilloma)  or  malignant  growths.  Rest 
to  the  voice  is  of  material  benefit.  In  very  protracted  cases  change  of 
air  and  constitutional  treatment.  Faradization  of  the  larynx  is  often 
very  serviceable  to  relieve  aphonia. 

IJ     Codeinse  sulph gr  ss  0.033 

Creosoti  carbon 3i  4.00 

Syr.  acaciae q.s  ad  Sii        60.00 

M. 

S. — One  teaspoonful  every  three  hours  for  a  child  six  years  old. 


DISEASES   OF    THE   RESPIRATORY   SYSTEM  313 

Edema  Glottidis 

(Submucous  Laryngitis,  Phlegmonous  Laryngitis) 

Edema  of  the  upper  portion  of  the  larynx  occurs  in  two  forms :  Active 
(inflammatory,  phlegmonous),  and  passive  (serous).  Inflammatory  ede- 
ma may  be  primary,  usually  traumatic  {e.g.,  scalds  or  burns),  or  sec- 
ondary, as  a  result  of  extension  of  inflammation  from  neighboring  struc- 
tures. Passive  edema  is  usually  observed  in  connection  with  grave  kid- 
ney and  heart  disease — often  long  before  dropsy  is  manifested  in  any 
other  part  of  the  body — and  secondarily  to  pressure  on  the  larynx  by 
swellings  or  growths. 

Pathologically  edema  of  the  larynx  consists  of  a  yellowish-white  or 
reddish  tumefaction — a  serous,  seropurulent  or  sanguinolent  transuda- 
tion into  the  submucosa — involving  the  upper  portions  of  the  larynx, 
the  epiglottis,  the  ary epiglottic  folds,  the  false  (rarely  the  true)  vocal 
cords,  and  the  mucous  membrane  of  the  arytenoid  cartilages. 

These  local  changes  can  readily  be  detected  by  inspection  of  the 
larynx,  often  without  the  mirror,  by  simply  depressing  the  tongue  and 
pulling  it  forward,  and  by  digital  examination. 

The  result  of  such  swelling  of  the  laryngeal  tissues  is  quite  obvious — 
namely,  interference  with  normal  respiration.  The  dyspnea  is  at  first 
paroxysmal,  and,  if  the  edema  is  not  very  marked,  only  moderately  se- 
vere. The  poor  little  patient  hacks  and  coughs,  in  vain  trying  to  clear 
the  throat.  If  the  edema  advances,  which  is  apt  to  occur  in  severe 
traumatic  cases,  the  dyspnea  may  become  extreme,  and  symptoms  of  as- 
phyxia may  set  in  which,  if  not  promptly  relieved,  may  lead  to  a  fatal 
issue. 

Edema  glottidis  should  not  be  mistaken  for  spasmodic  croup  or 
asthma ! 

Treatment. — Partial  edema  may  be  reduced  by  ice  bags  to  the  neck, 
swallowing  of  ice,  local  application  of  suprarenal  extract  solution 
(1:1000)  and  morphine  and  pilocarpine  hypodermically.  In  severe 
cases,  scarification  and,  if  need  be,  tracheotomy  should  be  resorted  to 
in  addition  to  the  mode  of  treatment  just  outlined.  Recurrence  of  an 
attack  of  passive  edema  should  be  prevented  by  prompt  attention  to 
the  etiologic  factors. 

Laryngeal  Tumors 

Neoplasms  of  the  larynx  are  very  rarely  seen  in  children.  This  is 
especially  true  of  malignant  growths.  Granulomata  are  occasionally 
observed  after  tracheotomy.  Papillomata  are  not  quite  so  rare,  and  are 
sometimes  congenital,  in  which  event  the  symptoms  usually  appear  soon 


314  DISEASES   OF    CHILDREN 

after  birtli.  Their  usual  seat  is  at  the  true  voeal  cords,  and  if  of  con- 
siderable size  they  give  rise  to  obstinate  cough,  hoarseness,  dyspnea  and 
attacks  of  asphyxia.  These  symptoms  develop,  however,  gradually,  and 
sometimes  disappear  spontaneously  owing  to  retrograde  metamorphosis 
of  the  tumor.  Recurrences  after  removal  of  the  tumor  are  frequent. 
Laryngeal  neoplasms  may  be  confounded  with  adenoids,  retropharyngeal 
abscess  and  croup,  but  the  diagnosis  can  readily  be  made  by  laryngo- 
scopic  examination.  Operative  treatment  should  be  instituted  only  in 
cases  presenting  troublesome  symptoms.  Endolaryngeal  removal  of  the 
growth  is  the  procedure  of  choice.  Tracheotomy  is  indispensable  in 
threatening  asphyxia. 

Foreign  Bodies  in  the  Larynx 

Various  articles  of  food,  little  playthings,  buttons,  needles,  ascarides, 
etc.,  may  find  their  way  into  the  larynx.  Small  foreign  bodies  are  usu- 
ally expelled  by  the  attacks  of  forcible  coughing.  Large  nonimpacted 
articles  may  be  removed  by  an  extubator  or  similar  forceps  after  co- 
cainizing the  upper  part  of  the  larynx.  Foreign  bodies  firmly  impacted 
in  the  larynx  should  be  removed  under  anesthesia  through  the  trache- 
otomy incision.  In  threatening  asphyxia,  tracheotomy  should  be  per- 
formed immediately  irrespective  of  subsequent  procedures.  To  re- 
duce hyperemia,  ice  externally  and  internally.  Local  antiphlogosis 
(Lugol's  solution,  1  per  cent  nitrate  of  silver)  after  removal  of  the 
foreign  body. 

Anodynes  for  the  relief  of  pain  and  irritability.  (For  removal  of 
ascarides  see  p.  280.) 

Diseases  of  the  Bronchial  Tubes,  Lungs  and  Pleura 

Bronchitis  Acuta 

(Tracheobronchitis,   Fibrinous  Bronchitis,   Capillary  Bronchitis) 

As  the  term  indicates  tracheobronchitis  is  a  catarrhal  inflammation 
of  the  trachea  and  large  bronchi.  It  usually  develops,  by  extension,  sec- 
ondarily to  nasopharyngeal  and  laryngeal  catarrh,  either  in  association 
with  ordinary  colds  or  in  consequence  of  specific  infections  such  as  in- 
fluenza, pertussis,  diphtheria  and  the  like.  Occasionally  it  is  met  as  a 
result  of  traumatism  by  irritating  vapors  or  dust.  Except  for  the 
harsh  cough,  which  is  at  first  dry  and  later  soft  and  yielding,  a  moderate 
amount  of  mucous  and  mucopurulent  expectoration,  slight  embarrass- 
ment of  respiration,  slight  temperature  and  anorexia,  simple  bronchitis 
is  usually  a  benign  affection  terminating  favorably  within  a  week  or  ten 
days.    Its  seriousness  consists  only  in  its  tendency  towards  the  develop- 


DISEASES   OF    THE    RESPIRATORY    SYSTEM  315 

ment  in  bronchopneumonia — which  is  most  apt  to  occur  in  young  in- 
fants or  older  children  whose  health  has  been  undermined  by  previous 
illness.  The  physical  signs  are  usually  limited  to  diffuse  large  soft  rfdes 
which  temporarily  disappear  after  brisk  coughing. 

Fibrinous  Bronchitis. — This  form  differs  from  simple  bronchitis  by 
the  presence  of  membranous  masses  of  mucus  and  fibrin  in  the  ex- 
pectoration, in  the  form  of  bronchial  casts.  The  casts  correspond 
to  the  size  and  depth  of  the  bronchi  involved.  Until  relieved  by  the 
ejection  of  the  casts,  the  patients  suffer  from  more  or  less  marked 
dyspnea  and  fever. 

Capillary  Bronchitis. — In  this  form  of  the  disease  the  small  bronchi, 
the  bronchioles,  are  involved,  and  it  is  often  questionable  whether  or 
not  the  inflammation  actually  remains  limited  to  the  fine  bronchi  or 
extends  to  the  pulmonary  alveoli.  As  a  rule,  capillary  bronchitis 
begins  as  a  simple  bronchitis,  but  as  it  progresses,  its  symptomatology 
is  essentially  the  same  as  in  the  early  stages  of  bronchopneumonia: 
thus,  painful  cough,  more  or  less  dyspnea,  moderate  or  high  fever, 
often  vomiting  and  twitching,  pallor,  and  cyanosis.  Fine  sibilant 
rales  are  heard  over  different  portions  of  the  chest,  and  sometimes 
also  fine  crepitation.  Unless  the  affection  is  arrested  in  its  early  course, 
its  transition  into  bronchopneumonia  is  the  rule. 

Treatment. — The  patient  should  be  kept  in  bed  in  a  well-ventilated 
warm  room;  the  diet  reduced  to  liquids,  and  the  bowels  regulated.  The 
nasopharynx  should  be  cleansed  a  few  times  daily  Avith  Dobell's  solu- 
tion (50  per  cent)  or  weak  solutions  of  the  newer  silver  prepara- 
tions. Inhalations  of  antiseptic  vapors  (with  the  compound  tincture 
of  benzoin  and  eucalyptol)  may  be  added  as  a  routine  procedure. 
Where  the  cough  is  painful,  and  distressing,  the  flaxseed  mustard 
poultice  recommended  in  bronchopneumonia  (q.  v.)  will  often  give 
relief  and  occasionally  arrest  the  disease  in  its  inception.  The  following 
preparations  will  be  found  very  serviceable: 


J^     Liq.  Animonii  Anisati 

Vini  Ipeeacuanhae 
Potassii  Citratis 

aa  3  ss 
3i 

2.0 
4.0 

Syrupi  Picis 
Glycerini 
Aquae  Aiiisi 
M. 

q.s. 

aa 

3iv 

ad  f  g  ii 

15.0 

60.0 

S. — One  tcaspooiiful 

every 

two  to  four  hours,  for  a  child  three 

yearg  old. 

Where  the  cough  is  very  disturbing,   it  is   advisable   to   add   from 
1/24  grain  to  1/16  grain  of  codeine  to  each  teaspoonful  of  the  medicine. 


316  DISEASES    OF    CIIlIiDREN 

Occasionally  I  find  it  necessary  to  alternate  this  mixture  with  the  fol- 
lowing : 

IJ     Cicosoti  Carbonatis  3  ss  2.0 

Glyeerini  3  iv  15.0 

Pulv.  et  Mucilago  Acacise  q.  s. 

Aquae  Aiiisi  q.  s.  ad  f  S  ii  CO.O 

M. 
S. — One  teaspoonful  cveiy  three  to  six  Iioiirs  for  a  child  three 
years  old. 

Bronchitis  Chronica 

Chronic  bronchitis  is  not  very  common  in  children.  It  may  occur 
as  a  sequel  of  acute  bronchitis  or  pneumonia,  diphtheria,  pertussis 
and  heart  and  kidney  diseases.  It  may  gradually  give  rise  to  dilata- 
tion of  the  bronchi  (bronchiectasis),  emphysema  or  asthma,  in  which 
event  the  symptomatology  resembles  that  of  the  other  affections. 
A  Roentgenogram  is  often  helpful  in  the  diagnosis.  This  procedure 
is  especially  valuable  in  the  detection  of  foreign  bodies  in  the  bronchi 
and  tuberculous  foci. 

Treatment. — Attention  to  the  nasopharynx  and  larynx.  Inhalation 
of  medicated  vapors.  Small  doses  of  ammonium  iodide  or  the  syrup 
of  hydriodic  acid.  Change  of  air.  General  tonics.  (See  also  Asthma, 
Bronchiectasis,  and  Emphysema.) 

Broncho  or  Lobular  Pneumonia 

Next  to  gastrointestinal  diseases,  bronchopneumonia  is  the  most  com- 
mon affection  of  early  childhood.  In  the  majority  of  cases  it  is  caused 
by  a  mixed  bacterial  infection — of  the  pneumococcus,  streptococcus, 
staphylococcus  aureus,  B.  influenzae  and  B.  tuberculosis.  It  frequently 
occurs  also  secondarily  to  the  exanthematous  diseases,  pertussis,  erysipe- 
las and  chronic  heart,  kidney,  and  intestinal  maladies.  Recurrent  colds, 
rachitis  and  other  wasting  diseases  serve  as  active  predisposing  causes. 

The  onset  of  bronchopneumonia  may  be  sudden  or  gradual  in  asso- 
ciation with  tracheobronchitis  or  capillary  bronchitis,  as  a  result  of  ex- 
tension of  the  inflammation.  The  pathologic  process  is  usually  bilateral. 
Small  areas  of  pulmonary  congestion,  consolidation  and  resolution  are 
scattered  throughout  the  entire  lung.  On  section  the  affected  lobules 
present  quite  a  smooth  surface  of  bluish-red  color.  The  bronchioles  and 
pulmonary  alveoli  are  filled  with  a  mucosanguinolent  and  mucopurulent 
exudation.  The  bronchial  walls  are  thickened  and  infiltrated  with  small 
round  cells,  and  the  lymph  nodes  are  enlarged  and  congested.  Quite 
often  the  pleura  is  implicated  in  the  inflammatory  process. 


DISEASES    OF    THE    RESPIRATORY    SYSTEM  317 

As  already  stated,  transition  of  the  inflammation  from  the  large 
bronchi  to  the  fine  bronchioles  (bronchiolitis)  and  lung  tissue  (pneu- 
monitis) not  rarely  proceeds  insidiously,  in  fact,  the  bronchopneumonia 
may  exist  for  a  few  days  before  being  detected.  This  holds  true  espe- 
cially of  bronchopneumonia  accompanying  influenza,  measles  and  diph- 
theria. In  the  majority  of  cases,  however,  the  onset  is  ushered  in  with 
rise  of  temperature  (up  to  105°  F.),  fretfulness,  vomiting,  and  occa- 
sionally convulsions.  The  cough  is  dry,  short  and  painful,  the  pulse 
and  respiration  are  greatly  increased  in  frequency.  A  pulse  of  130  to 
160  beats  per  minute  and  a  respiratory  rate  of  from  40  to  60  are  quite 
common.  There  is  moderate  dyspnea;  the  alse  nasi  are  contracting  and 
dilating  forcibly ;  the  eyes  are  dull,  and  the  face  is  pale  and  slightly 
cyanotic.  In  virulent  cases  the  dyspnea  gradually  increases,  the  heart's 
action  becomes  weaker,  and  the  patient  rapidly  succumbs  to  cardiac  ex- 
haustion and  toxemia,  usually  preceded  by  attacks  of  tachycardia  and 
tachypnea,  coma  and  convulsions.  Even  in  favorable  cases,  the  course 
of  the  disease  is  usually  protracted,  lasting  from  two  to  four  weeks  or 
longer,  principally  because  of  repeated  extension  of  the  pneumonic  proc- 
ess to  new  areas,  not  rarely  with  resolution  of  the  old  foci.  Furthermore, 
the  course  of  the  disease  is  often  aggravated  by  numerous  complications : 
as,  for  example,  pleuritis,  otitis,  stomatitis  and  gastroenteritis,  and  quite 
frequently  also  by  pyothorax.  Where  resolution  is  long  delayed,  bron- 
chopneumonia may  also  terminate  in  tuberculosis  and  pulmonary  gan- 
grene. 

The  physical  signs  are  indefinite  in  the  early  stage  of  the  affection. 
The  face  is  flushed  on  one  or  both  sides  and  with  each  inspiration  there 
is  more  or  less  marked  retraction  of  the  soft  structures  in  the  intercostal 
and  suprasternal  spaces.  The  respiratory  sounds  are  rough  and  accen- 
tuated, and  here  and  there  intensified  by  diffuse  small  and  large  sono- 
rous rales.  As  the  disease  advances  and  the  localized  pneumonic  foci 
multiply,  become  consolidated  and  coalesce,  we  are  soon  able  to  detect 
the  typical  signs  of  pneumonia,  i.  e.,  dulness  on  percussion,  bronchial 
breathing,  bronchophony  and  occasional  fine  crepitation.  An  undue  de- 
gree of  flatness  on  percussion  should  be  looked  upon  as  a  suspicious  sign 
of  pleuritis  with  effusion. 

The  prognosis  of  bronchopneumonia  is  always  very  grave,  especially 
in  infants  under  one  year  of  age,  in  whom  the  mortality  ranges  between 
20  and  30  per  cent.  Grave,  often  fatal,  are  usually  the  cases  presenting 
the  following  symptoms:  continued  hyperpyrexia,  pallor  and  cyanosis, 
marked  tympanites,  dyspnea  with  respirations  irregular  in  depth  and 
rhythm,  coma  and  convulsions,  and  recurrent  recrudescence  of  the  pneu- 


318  DISEASKS   OF   CHILDREN 

monic  process  after  apparent  defervescence.  (See  also  Influenza-  Pneu- 
monia.) 

Treatment. — Bronchopneumonia  being  most  frequently  the  sequel  of 
some  other  serious  affection,  it  is  therefore  obvious  that  prophylaxis 
forms  the  sine  qua  non  in  our  therapeusis.  By  viewing  every  simple  na- 
sopharyngeal and  bronchial  catarrh  as  a  precursor  of  lobular  pneumonia, 
and  by  applying  the  proper  means  to  arrest  it  at  its  inception,  a  great 
many  cases  could  readily  be  prevented.  Bronchopneumonia,  once  es- 
tablished, we  have  no  specific  to  combat  it.  However,  an  attempt  can 
yet  to  be  made  to  modify  the  virulence  of  the  disease  by  means  of  the 
following  procedures.  The  patient  is  given  a  hot  mustard  bath  of  about 
three  minutes'  duration,  is  wrapped  in  a  warm  blanket,  surrounded  by  a 
few  hot  water  bags  and  given  hot  drinks,  moderate  doses  of  sweet 
spirits  of  niter  or  spirit  Mindererus,  etc.,  to  stimulate  free  diaphoresis. 
This  is  soon  followed  by  the  application  to  the  chest  and  back  of  a  hot 
poultice  consisting  of  six  tablespoonfuls  of  flaxseed  meal,  three  table- 
spoonfuls  of  camphorated  oil,  one  or  two  tablespoonfuls  of  powdered 
mustard  and  a  sufficient  quantity  of  hot  water  to  make  a  thick  paste 
by  thorough  stirring.  The  mass  is  spread  thickly  on  thin  gauze.  The 
child  is  then  wrapped  in  an  oiled  silk  jacket  lined  with  absorbent 
cotton  and  blanket,  which  with  the  hyperpyrexia  of  the  body,  main- 
tain the  heat  of  the  poultice,  so  that  its  renewal  is  required  but  three 
or  four  times  in  twenty-four  hours.  The  poultice  is  very  useful,  espe- 
cially where  the  breathing  is  painful  and  difficult.  In  these  cases  some 
benefit  may  be  derived  from  the  application  of  from  twelve  to  twenty- 
four  dry  cups.  Where  the  temperature  is  very  high  and  the  poultice  is 
apt  to  interfere  with  the  hydrotherapeutic  procedures,  we  may  resort  to 
mustard  cloths  (wrung  out  of  a  mustard  solution,  one  teaspoonful  of 
mustard  to  a  pint  of  w^arm  water).  The  temperature  should  preferably 
be  reduced  by  cool  sponging,  cool  pack,  ice  cap  to  the  head,  and  where 
cerebral  symptoms  prevail,  by  warm  baths,  with  or  without  mustard, 
although  an  occasional  dose  of  pyramidon,  aspirin  or  phenacetin  will  do 
no  harm. 

The  maintenance  of  the  child's  strength  is  most  essential  to  the  suc- 
cessful management  of  the  disease.  Be  it  remembered  that  death  in 
pneumonia  is  due  to  heart  failure  and  not  to  pulmonary  insufficiency; 
therefore,  the  heart  must  receive  early  and  diligent  attention.  "We  may 
begin  with  the  tinctures  of  digitalis  and  strophanthus  (one  drop  of  each 
for  every  year  of  the  child's  age  up  to  about  six  years)  every  four  to 
six  hours,  and  more  frequently  if  the  circulatory  and  respiratory  diffi- 
culty increases.  In  bad  cases  the  stimuluation  may  be  intensified  by  the 
addition  of  sterile  camphorated  oil  (3  grains)  and  strychnine  sulphate 


DISEASES   OF    THE   RESPIRATORY    SYSTEM  319 

(1/60  grain)  hypodermically  every  four  hours;  and  where  signs  of 
pulmonary  edema  supervene,  by  an  occasional  dose  of  atropine  sul- 
phate (1/200  grain).  In  sudden  collapse,  suprarenal  solution  (5  to  10 
minims  hypodermically)  is  worth  trying. 

Every  effort  should  be  made  to  rejjlenish  the  body  fluids  consumed 
during  the  active  febrile  process  by  suitable  liquid  nourishment,  such 
as  broths,  beef  tea,  small  quantities  of  milk  or  fermented  milk,  fruit 
juice,  etc.,  in  addition  to  large  quantities  of  water.  In  extreme  cases, 
saline  entero-  or  hypodermoclysis,  and,  in  older  children,  saline  intra- 
venous maj-  have  to  be  resorted  to.  The  urine  should  be  watched  for 
acetone  and  pus,  the  latter  especially  in  girls.  Excessive  tympanites 
often  yields  to  intestinal  irrigations  with  bicarbonate  of  soda  solutions 
(14  ounce  to  2  quarts  of  water)  with  or  without  the  addition  of  essence 
of  peppermint  (10  to  15  minims)  or  to  pituitary  solution  hypodermically. 
This  may  be  repeated  two  or  three  times  in  twenty-four  hours.  Com- 
plications arising  should  receive  prompt  attention. 

When  called  upon  to  treat  bronchopneumonia  with  delayed  resolution, 
our  efforts  should  be  directed  mainly  towards  the  prevention  of  empy- 
ema or  tuberculous  infiltration  of  the  lungs.  A  great  deal  can  be  ac- 
complished by  placing  the  patient  in  a  large  airy  room  during  the 
febrile  stage,  and,  weather  permitting,  keeping  him  outdoors  most  of 
the  time,  after  the  temperature  has  dropped  to  normal  or  to  a  degree 
above.  During  convalescence  removal  to  the  country  is  highly  to  be 
recommended. 

The  iodides  will  often  be  found  very  useful  to  hasten  resolution.  We 
usually  begin  the  administration  of  the  sodium  or  ammonium  iodide, 
in  1^  to  2  grain  doses,  about  the  sixth  day  of  the  disease,  and  continue  it 
until  resolution  has  been  established.  After  the  temperature  has  disap- 
peared, we  give  the  syrup  of  the  iodide  of  iron  with  the  compound 
syrup  of  hypophosphites,  which  acts  both  as  an  alterative  and  tonic. 

Creosote  is  indicated  in  all  stages  of  bronchopneumonia  (see  Prescrip- 
tion, p.  316).  The  ordinary  beechwood  creosote  maj^  also  be  used  for  in- 
halation by  means  of  a  croup  kettle  (10  to  20  minims  in  a  pint  of  hot  wa- 
ter). Its  effect  is  intensified  if  a  tent  is  improvised  around  the  child's 
bed. 

If  notwithstanding  the  aforementioned  therapeutic  measures  the 
bronchopneumonia  fails  to  resolve,  and  the  physical  signs  and  explora- 
tory puncture  fail  to  disclose  pus  in  the  thorax,  we  must  direct  our  at- 
tention to  the  possible  presence  of  a  latent  or  florid  tuberculous  process. 
The  diagnosis  between  simple  bronchopneumonia  due  to  mixed  infection 
and  acute  or  subacute  tuberculous  bronchopneumonia  is  often  very  diffi- 
cult. In  the  tuberculous  variety  the  onset  is  usually  more  gradual,  the 
temperature  curve  more  intermittent,  the  loss  in  weight  more  rapid  and 


320  DISEASES   OF    CHILDREN 

the  areas  of  consolidation  more  stationary  in  character,  and  giving  rist 
to  more  definite  physical  signs,  such  as  flatness,  bronchial  breathing, 
bronchophony,  etc.  An  exact  roentgenogram  is  often  decisive  in  the 
diagnosis,  revealing,  as  it  frequently  does,  marked  involvement  of  the 
bronchial  glands.  The  von  Pirqnet  test  is  usually  negative  in  the  non- 
tuberculous  form. 

Lobar  Pneumonia 

(Croupous  Pneumonia,  Fibrinous  Pneumonia,  Pneumonitis,   Pneu- 

Mococcus  Pneumonia) 

Acute  lobar  pneumonia  is  a  primary,  specific,  communicable, 
occasionally  epidemic,  affection  of  the  lungs,  pathologically  character- 
ized by  pulmonary  engorgement,  red  hepatization,  gray  hepatization  and 
resolution.  The  pneumococcus  or  diplococcus  lanceolatus  of  Frankel- 
"Weichselbaum,  the  immediate  cause  of  lobar  pneumonia,  can  readily  be 
isolated — usually  in  pure  culture — in  the  sputum,  lung  substance,  and  the 
blood,  in  four  different  groups — Type  I,  II,  III,  IV.* 

Pathology. — In  the  stage  of  e^igorgemerit  or  congestion  the  lungs  show 
very  little  that  is  characteristic.  They  are  dark  red,  still  contain  air,  but 
are  slightly  firmer  in  consistence,  and  resemble  mostly  a  beginning 
hypostatic  pneumonia.  Without  the  aid  of  the  microscope  it  can  be 
anatomically  diagnosed  best  when  fibrinous  hepatization  is  to  be  seen 
immediately  adjoining  it. 

In  the  stage  of  red  hepatization  the  alveoli  become  filled  with  red 
blood  corpuscles  and  fibrin.  On  coagulation  of  the  fibrin  the  hemor- 
rhagic contents  of  the  alveolus  become  a  quite  firm,  red  plug.  The  cut 
surface  of  red  hepatization  is  red  and  slightly  granular.  The  latter 
gradually  changes  to  grayish-red  and,  in  part,  grayish-yellow  (gray 
hepatization).  This  is  due  to  solution  of  the  blood  corpuscles,  diffusion 
of  the  blood  coloring  matter,  and  exudation  of  new  fibrin  masses  and 
partly  also  of  cellular  elements  into  the  alveoli.  The  hepatized  area 
thus  attains  a  volume  as  in  deep  inspiration,  with  the  difference,  how- 
ever, that  instead  of  air  a  firm  exudate  occupies  the  alveoli  which  pro- 
duces anemia  of  the  lung  tissues  as  a  result  of  pressure  upon  the  vessels. 
If  the  edge  of  a  knife  is  held  at  a  slant  and  scraped  across  the  cut  sur- 
face, grayish-yellow  granules  are  obtained,  which  are  composed  of  a 
dense  network  of  fibrin  inclosing  a  moderate  number  of  colorless  blood 
corpuscles  and  a  few  desquamated  alveolar  epithelia.  This  is  the  stage 
of  complete  hepatization. 


•Blanke    and    Cecil    (Jour.    Kxp.    Med.,    April,    1920)    have    shown    that    lobar    pneumonia    is 
bronchiogenic  in   character.      Invasion   of  the  blood   stream   by   pneumococci   is  secondary. 


DISEASES    OF    THE    RESPIRATORY    SYSTEM  321 

The  cut  surface  gradually  becomes  smoother  and  redder,  and  the 
solid  consistency  gives  place  to  a  more  relaxed  condition.  If  the  cut 
surface  now  be  scraped  with  the  edge  of  a  knife,  a  cloudy  fluid,  partly 
mixed  with  solid  masses,  is  seen,  which  consists  microscopically  of  finely 
granular  detritus,  disintegrated  cells  and  a  few  large,  still  coherent 
clumps  or  plugs.  These  plugs  contain  chiefly  round  cells  and  only  a 
slight  amount  of  fibrin.  This  is  the  stage  of  resolution,  i.  e.,  loosening, 
softening,  transformation  from  the  solid  to  the  fluid  state ;  the  exudation 
is  partly  expectorated  and  partly  absorbed,  as  a  result  of  a  fermentative, 
proteolytic  process   (R.  Langerhans  and  H.  T.  Brooks). 

Lobar  pneumonia  is  generally  accompanied  by  fibrinous  pleuritis,  and 
more  or  less  marked  bronchitis.  As  a  rule,  only  one  pulmonary  lobe  is 
affected,  and  the  lower  right  more  frequently  than  the  others.  If  several 
lobes  are  involved,  it  usually  occurs  by  successive  invasion. 

Primary  fibrinous  pneumonia  usually  ushers  in  suddenly,  often  after 
exposure  to  cold  or  wet,  with  vomiting,  chilliness,  high  temperature 
and  more  or  less  marked  dyspnea.  The  initial  symptoms  are  frequently 
misleading.  They  may  consist  of  vomiting,  diarrhea,  pain  in  the  abdo- 
men and  nosebleed,  suggesting  the  beginning  of  typhoid  fever ;  or  con- 
vulsions, sopor,  vomiting  and  severe  muscular  pain  may  predominate, 
justifying  the  tentative  diagnosis  of  meningitis.  Where  the  pneumonic 
lesion  is  located  centrally  (so-called  central  pneumonia),  and  the 
physical  signs,  nay,  even  the  cough,  is  absent  or  very  slight  in  the 
early  stages  of  the  disease,  one  is  not  rarely  tempted  to  diagnose  re- 
mittent malarial  fever.  Furthermore,  there  are  also  numerous  cases 
of  pneumonia  of  only  a  few  days'  duration  (so-called  abortive  pneu- 
monia), which  undoubtedly  escape  observation  or  are  recognized  only 
by  their  critical  defervescence. 

Of  course,  the  majority  of  cases  pursue  a  typical  course  and  are 
readily  elicited  on  careful  physical  examination.  As  a  rule,  avisculta- 
tion  discloses  harsh  breathing  all  over  the  chest,  and  during  the  first 
stage  often  distant  breathing  over  the  affected  area  and  fine  crepita- 
tion along  its  edges.  In  the  second  stage,  when  the  consolidation  is 
complete,  the  breathing  is  distinctly  tubular  and  the  vocal  resonance 
bronchial  in  character  (bronchophony).  In  the  third  stage,  with  be- 
ginning resolution,  fine  crepitant  rales  (crepitatio  redux)  return,  but 
are  often  softer  in  quality.  Bronchophony  may  continue  long  into  con- 
valescence. In  the  first  day  or  two  of  the  disease  the  percussion  sound 
is  usually  tympanitic — owing  to  the  presence  of  soipe  air  in  the  in- 
volved lung,  but  as  the  consolidation  advances,  we  readily  elicit  dul- 
ness  or  flatness,  the  experienced  hand  perceiving  also  a  distinct  in- 
creased sense  of  softness  and  resistance  which  is  transmitted  to  the 


322 


DISEASES   OF    CHILDREN 


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Fig.   74. — Fever   curve   of  a  fatal   ease   of   apex   pneumonia   with   marked   cerebral 
symptoms  in  a  child  two  years  old. 


percussed  finger.  Pectoral  fremitus  is  ordinarily  not  pronounced  in 
young  children,  except  when  they  cry  aloud,  which  act  should  always 
be  encouraged  to  facilitate  the  exposition  of  the  physical  signs.  In 
all  stages  of  pneumonia,  inspection  reveals  more  or  less  marked  dysp- 


DISEASES   OF   THE   RESPIRATORY   SYSTEM  323 

nea,  dilatation  of  the  alas  nasi,  and  depression  of  the  peripneiimonic 
groove  with  each  inspiration. 

Croupous  pneumonia  generally  runs  a  self-limited  course,  from  five 
to  thirteen  days  or  longer,  and  most  frequently  terminates  by  crisis, 
at  a  time  when  the  disease  is  at  its  height.  Until  then,  especially  in 
the  absence  of  complications,  there  is  little  change  in  the  clinical  pic- 
ture of  the  affection.  The  fever  remains  high  (104°  to  105°  F.  or 
higher)  with  slight  remissions;  the  pulse  and  respiration  ratio  is  greatly 
disturbed,  from  1 :2l/2  to  1 :2 ;  the  cough  short,  dry  and  painful,  and 
in  older  children  often  attended  with  rusty  expectoration ;  the  face  is 
pale  with  a  hectic  flush  and  the  nose  and  lips  are  more  or  less  cyanotic ; 
the  urine  is  scanty,  highly  colored,  rich  in  salts  (with  diminution  in  chlo- 
rides) and  occasionally  in  peptone  and  acetone;  the  tongue  heavilj^ 
coated,  sometimes  blackish  with  its  tip  red ;  and  finally  the  abdomen  is 
considerably  distended.  The  child  is  very  restless,  listless,  tosses  from 
side  to  side,  and  when  able  to  respond  to  questions,  usually  indicates 
the  seat  of  pain  someAvhere  in  the  abdomen,  usually  on  the  side  where 
the  lung  is  affected. 

As  the  crisis  approaches  and  the  circulatory  difficulties  become  more 
and  more  pronounced,  the  expiratory  moan  becomes  louder  and  longer, 
the  cough  more  harassing,  the  breathing  more  superficial,  the  pulse 
more  rapid  and  feeble,  the  thirst  more  intense,  and  the  sensorium  more 
disturbed, — the  child  lies  helpless,  often  rigid,  in  a  state  of  apathy, 
frequently  interrupted  by  incoherent  outcries  and  on  the  verge  of  col- 
lapse. The  change  wrought  by  the  establishment  of  the  crisis  is  cer- 
tainly miraculous.*  In  but  a  few  minutes  the  heart's  action  calms 
down  (the  pulse  is  often  irregular  and  very  feeble),  the  breathing  be- 
comes slower  and  deeper,  and  the  patient  bathed  in  perspiration  falls 
into  a  more  or  less  profound  sleep,  from  which  he  often  aAvakens  fully 
refreshed,  free  from  pain  and  fever  (sometimes  2  or  3  degrees  below 
normal),  ready  to  take  nourishment,  and  happy  to  start  life  anew. 

Unfortunately  the  typical  course  of  the  disease  is  often  marred  by 
a  number  of  complications,  and  even  without  these,  pneumonia  may 
prove  fatal,  the  mortality  ranging  between  from  10  to  20  per  cent.  Not 
rarely,  lobar  pneumonia  terminates  by  lysis.  Defervescence  may  be 
tardy,  the  temperature  reaching  normal  by  two  or  three  stages.  Oc- 
casionally, after  an  apparently  true  crisis  and  durable  defervescence, 
recrudescence  takes  place,  the  temperature  again  rising  and  continu- 
ing for  several  days.    In  some  instances  where  the  pneumonia  is  greatly 


*The  crisis  and  resolution  of  the  pneumonic  process  seems  to  be  due  to  local  biochemic 
changes,  in  the  course  of  which,  as  suggested  by  Lord  (Jour.  Exp.  Med.,  October,  1919),  the 
acid  death  point  of  the  pneumococcus  is  reached. 


324  DISEASES    OF    CHILDREN 

protracted,  the  inflammatory  process  is  found  to  "creep"  from  lobe 
to  lobe,  and  may  end  either  in  gradual  recovery  or  in  unresolved, 
chronic  or  the  so-called  caseous  pneumonia.  Very  serious  also  are  the 
cases  in  which  the  lung  involvement  is  very  extensive  (double  pneu- 
monia) from  the  start;  where  the  inflammation,  spreading  to  the 
pleura  (pleuropneumonia);  gives  rise  to  free  effusion  which,  through 
secondary  infection,  terminates  in  pyothorax;  and  where  the  pneu- 
monia supervenes  upon  other  infectious  diseases  (e.  g.,  influenza,  diph- 
theria), more  especially  if  it  is  preceded  by  cardiac  exhaustion  from  the 
effects  of  the  underlying  affection.  Occasionally  fulminating  pneu- 
monia is  met  with,  whicli  is  manifested  by  extreme  dyspnea,  cyanosis, 
tympanites,  high  continuous  temperature,  very  rapid  and  feeble  pulse, 
and  cerebral  symptoms,  and  ends  fatally  within  two  or  three  days. 
These  cases  are  usually  due  to  mixed  infection. 

Complications  also  substantially  mar  the  prognosis  as  regards  the  im- 
mediate and  ultimate  recovery,  meningitis  and  pericarditis  proving 
particularly  disastrous.  As  already  stated,  pleurisy,  with  a  serous  and 
more  especially  purulent  effusion,  is  more  apt  to  influence  the  prognosis 
at  a  later  stage.  Pneumococcus  peritonitis  is  a  very  grave  complication, 
but  recovery  may  ultimately  ensue  if  the  pus  in  the  peritoneal  cavity 
becomes  encapsulated  and  finds  its  way  out  either  through  the  intes- 
tines or  the  umbilicus.  Suppurative  foci  (pneumococeic  metastases) 
are  occasionally  encountered  in  the  bones  and  joints  and  ordinarily  yield 
to  surgical  procedures.  Among  other  complications,  we  may  also  men- 
tion otitis  media,  which  usually  clears  up  with  or  without  perforation. 

The  relation  between  a  high  leucocytosis  and  favorable  prognosis  in 
lobar  pneumonia  is  still  subject  to  controversy.  Generally  fibrinous 
pneumonia  is  associated  with  a  high  leucocytosis,  the  proportion  of  the 
white  cells  to  the  red  ranging  anywhere  between  1  to  40  to  1  to  70,  which 
is  nearly  twice  as  high  as  in  the  lobular  variety.  According  to  Koplik, 
a  very  low  leucocyte  count  with  marked  signs  of  pneumonia  and  high 
temperature  is  a  grave  prognostic  sign.  Such  eases,  however,  may  re- 
cover. On  the  other  hand,  even  a  high  leucocytosis,  with  extensive  in- 
flammation of  both  lungs,  does  not  prevent  a  fatal  issue. 

Differential  Diagnosis.— In  the  initial  stage  lobar  pneumonia  may  be 
confounded  with  bronchopneumonia,  pleurisy,  meningitis,  and  appen- 
dicitis ;  in  the  second  stage  with  pleurisy  with  effusion,  and  in  the  ab- 
sence of  cough  and  the  presence  of  marked  tympanites,  with  peri- 
tonitis; and  in  the  third  stage,  especially  where  resolution  is  delayed, 
with  miliary  tuberculosis.  Moreover,  concurrence  of  pericarditis  may 
occasionally  obscure  the  original  disease.  Careful  attention  to  the 
pathognomonic  signs  and  symptoms  of  the  different  affections  ought  to 


DISEASES    OF    THE   RESPIRATORY    SYSTEM 


325 


readily  clear  up  the  diagnosis.  We  must,  however,  always  bear  in 
mind  the  fact  that  any  of  the  aforementioned  diseases  may  at  any 
time  complicate  the  pneumonia.  In  doubtful  cases,  a  careful  differ- 
ential count,  and,  in  hospital  practice,  an  x-ray  examination  will  often 
facilitate  the  diagnosis. 


Acute  Lobar  Pneumonia 

Generally  a  primary  disease. 
Onset  sudden. 
High  regular  fever. 
Inflammatory  process  localized. 
Physical   signs   distinct. 
Termination  Ijy  crisis,  the  rule. 

Acute  Lobar  Pneumonia 
Onset  sudden  and  marked. 
Fever  high  and  regular. 
Tuberculin  test  negative. 
Complement-fixation  test  negative. 
Sputum  contains  pneumococci. 
Duration    from    one   to   two   weeks   with 
tendency  to  recovery. 
See  also  Pleurisy,  page  328. 


Catarrhal  Pneumonia 

Secondary. 
More  gradual. 
Moderate  and  irregular. 
More   diffuse. 
Indistinct. 
By  lysis. 

Miliary  Tuberculosis 
More  gradual  and  masked. 
Very  irregular. 
Positive,  as  a  rule. 
Positive  in  early  stage. 
Tubercle  bacilli. 
From  three  to  six  weeks,  ending  fatally. 


Treatment. — Pneumonia  being  a  communicable  affection,  it  calls  for 
all  such  hygienic  precautions  as  are  ordinarily  employed  in  the  pre- 
vention of  other  contagious  and  infectious  diseases.  (See  p.  68.) 
The  sputum  should  be  collected  in  small  pieces  of  gauze  and  destroyed. 

Fresh  cool  air  is  the  sine  qua  non  in  the  management  of  pneumonia. 
It  purifies  the  respiratory  tract,  eases  respiration,  facilitates  the  pul- 
monary circulation,  hence  relieves  and  regulates  the  heart's  action, 
reduces  temperature,  and  cheers  the  patient  in  those  endless,  wakeful 
hours,  which  are  so  characteristic  in  pneumonia,  and  last  but  not  least, 
disinfects  the  sick  room  and  thus  prevents  transmission  of  the  disease 
to  others,  as  well  as  autoinfection  of  the  patient. 

Plenty  of  pure  drinking  water  is  the  next  most  important  requisite. 
It  should  be  given  ad  libitum,  unless  contraindicated  by  uncontrollable 
vomiting.  Pure  water  cleanses  the  mouth,  pharynx  and  alimentary 
canal  which  in  children  with  pneumonia  are  usually  infected  by  the  large 
quantities  of  putrid  sputum  that  are  swallowed  rather  than  expectorated  ; 
it  quenches  the  ever-present  agonizing  thirst ;  stimulates  expectoration 
and  aids  in  reduction  of  temperature. 

It  is  advantageous  to  administer  daily  a  low  enema  containing  a  quart 
or  two  of  warm  water  with  an  ounce  of  bicarbonate  of  soda — to  cleanse 
the  bowels  and  to  relieve  intestinal  fermentation,  and  also  to  counteract 
the  acetonuria  which  is  quite  common  in  febrile  affections.     Saline  re- 


326  DISEASES   OF    CHILDREN 

tention  enemas  (105°  F.)  may  also  be  given  a  few  times  daily  to  stimu- 
late the  action  of  the  kidneys  and  heart. 

"Water  should  serve  as  the  only  antipyretic  when  reduction  of  fever 
is  indicated,  i.  e.,  if  above  102°  F.,  and  may  be  administered  in  the  form 
of  cold  sponges,  cold  packs,  warm  baths  and,  in  older  children,  even 
cool  baths  followed  by  brisk  friction,  if  the  temperature  remains  per- 
sistently high.  In  excessive  nerve  irritability  mustard  may  be  added 
to  the  warm  bath  (see  ''Hydrotherapy,"  p.  90),  although  in  such 
cases  an  occasional  dose  of  sodium  bromide  (5  grains)  and  pyramidon 
(2  grains)  will  often  act  very  beneficially. 

Pain  and  cough  in  pneumonia  may  be  readily  relieved  by  minute  doses 
of  codeine,  with  or  without  sodium  salicylate,  or  by  local  heat,  either 
in  the  form  of  a  flaxseed  and  mustard  poultice  (see  p.  318),  or  cloths 
immersed  in  warm  mustard  water,  wrung  out  and  covered  with  oiled 
silk  and  towel.  The  mustard  cloths  may  be  changed  every  half  hour 
until  the  pain  is  relieved.  In  some  cases  I  observed  very  good  results 
from  dry  cupping. 

Some  authors  claim  that  quinine  exerts  a  specific  action  in  pneumonia. 
It  must  be  pushed  to  its  full  physiologic  effect — 1  to  2  grains  for  every 
year  of  the  child's  age,  every  two  to  four  hours.  In  severe  cases,  qui- 
nine urea  hydrochloride  may  be  administered  intramuscularly. 

The  heart  action  requires  careful  watching.  Where  the  pulse  is  very 
rapid,  the  tinctures  of  digitalis  and  strophanthus  (one  drop  for  every 
year  of  the  child's  age)  may  be  given  alternately  every  three  hours,  while 
when  the  pulse  drops  below  one  hundred  per  minute,  strychnine  sul- 
phate (1/200  to  1/100  grain  hypodermically)  is  the  remedy  of  choice. 
The  "Murphy  drip"  is  a  valuable  stimulant  to  the  heart  and  kidneys. 
For  quick  stimulation  caffeine  sodium  benzoate  (1  to  3  grains  every 
six  hours)  should  also  be  resorted  to.  The  profession  is  generally  in 
favor  of  sterile  camphorated  oil  (3  grains),  although  I  believe  that  its 
therapeutic  effect  is  greatly  exaggerated.  In  threatening  pulmonary 
edema,  nitroglycerine  (1/200  grain)  may  prove  efficient.  It  is  well  to 
bear  in  mind,  however,  that  undue  overcrowding  of  stimulants  may  do 
harm.  In  cyanosis,  oxygen  is  beneficial.  In  severe  cases  of  tympanites, 
pituitary  solution  hypodermically  is  well  worth  trying. 

Protracted  and  unresolved  pneumonias  often  respond  promptly  to  the 
administration  of  ammonium  iodide  (1  grain  three  times  a  day  for  every 
year  of  the  child's  age). 

The  diet  should  be  light  and  easily  digestible,  consisting  mainly  of 
broths,  fruit  juices,  small  quantities  of  plain  or  fermented  milk,  albu- 
min water,  well  diluted  wine  or  cognac.  Milk  should  be  dispensed  with 
where  tympanites  is  marked. 


DISEASES    OF    THE   RESPIRATORY   SYSTEM  327 

The  mouth  and  nasopharynx  should  be  gently  cleansed  several  times 
daily. 

The  profession  is  still  at  odds  over  the  usefulness  of  vaccines  and  se- 
rums in  the  treatment  of  pneumonia.  If  the  type  of  the  pneumococcus 
can  readily  be  determined  and  the  homologous  serum  obtained,  it  could 
safely  be  administered,  even  though  we  have  as  yet  no  positive  evidence 
of  its  specific  effect. 

In  slow  convalescence  it  is  advisable  to  send  the  patient  to  the  moun- 
tains or  to  a  mild  seashore  resort  and  to  administer  creosote  by  mouth 
as  Avell  as  by  inhalation.  The  sj^rup  iodide  of  iron  and  cod  liver  oil 
are  indicated  especially  in  young  children.     See  ''Bronchopneumonia". 

Pleuritis 

(Pleurisy.    Empyema) 

The  pleura,  like  other  serous  membranes,  may  be  affected,  primarily 
as  a  result  of  trauma,  or  invasion  of  pathogenic  bacteria,  such  as  the 
pneumococcus,  streptococcus,  the  microbe  of  rheumatism,  influenza,  etc., 
or  secondarily  by  extension  of  an  inflammation  from  neighboring  struc- 
tures. Primary  pleurisy  is  comparatively  rare  in  young  children.  The 
secondary  variety,  however,  is  quite  common  in  connection  with  pneu- 
monia, influenza,  tuberculosis,  acute  heart  disease,  general  sepsis,  and 
affections  of  the  abdominal  organs. 

Pathologically,  pleuritis  is  characterized  by  congestion  and  rough- 
ness of  either  the  parietal  or  visceral  layer  of  the  pleura  or  of  both ; 
a  fibrinous  exudation  upon  the  pleura ;  in  severe  cases,  a  more  or  less 
large  collection  of  (serous,  serosanguinolent,  or  seropurulent)  fluid  be- 
tween the  surfaces  of  the  pleura,  or  between  the  gaps  and  meshes  of 
the  fibrinous  exudation.  In  accordance  with  the  extent  and  location 
of  the  pleural  effusion,  there  is  more  or  less  severe  displacement  of  the 
contiguous  structures. 

I.  Dry  Pleurisy 

It  is  quite  probable  that  many  cases  of  dry  pleurisy  in  young  chil- 
dren escape  detection.  This  is  apt  to  occur  especially  in  secondary 
pleurisy,  where  the  symptoms  of  the  original  disease  obscure  those 
of  the  complication.  Moreover,  little  patients  often  refer  the  pathog- 
nomonic "stitch  pain"  to  the  abdomen  instead  of  to  the  side.  Apart 
from  the  pain,  the  subjective  symptoms  are  few  and  mild.  The  child 
instinctively  abstains  from  coughing  "^nd  deep  breathing,  and  like  an 
adult  lies  on  the  affected  side.  As  a  rule,  the  diagnosis  can  readily  be 
made  on  hearing  the  pleuritic  friction  sound — a  dry,  crackling  sound 


328  DISEASES    OF    CHILDREN 

on  inspiration.  The  termintition  of  dry  pleurisy  is  either  in  rapid 
and  uneventful  recovery  (sometimes  leaving  behind  slight  pleural  thick- 
ening and  adhesions)  or  in  the  graver  form  of  the  malady,  i.  e.,  in 
pleurisy  with  eifusion. 

II.  Pleurisy  With  Effusion 

A  perceptible  pleural  effusion,  be  it  composed  of  serum,  blood  and 
serum,  pus  or  chyle  may  generally  be  recognized  by  the  following 
distinctive  features: 

Inspection. — Dyspnea  Avith  impairment  of  movement  of  the  affected 
side. 

In  large  effusions,  fullness  of  the  intercostal  spaces  and  later  bulg- 
ing of  the  affected  area  of  the  thoracic  wall,  and  not  rarely  promi- 
nence of  the  hypochondrium  of  the  corresponding  side.  Occasionally, 
enlargement  of  the  subcutaneous  veins,  and  superficial  edema.  In 
cases  of  long  standing  in  which  effusion  undergoes  partial  or  com- 
plete absorption  (as  well  as  after  operative  removal  of  the  fluid),  there 
is  a  lateral  curvature  of  the  spine,  incurvation  of  the  affected  side  with 
compensatory  bulging  of  the  unaffected  side  of  the  chest. 

Palpation. — As  compared  with  the  healthy  side,  there  is  distention 
of  the  intercostal  spaces  on  inspiration  and  diminution  of  vocal  frem- 
itus. In  large  serous  effusion,  fluctuation  may  be  perceived  by  placing 
one  finger  of  one  hand  in  the  intercostal  space,  and  with  the  finger 
of  the  other  hand  imparting  quick  but  gentle  impulses  to  the  fluid,  in 
the  direction  of  the  other  finger. 

Auscultation. — Varying  wuth  the  amount  of  pleuritic  effusion  or 
thickening,  the  respiratory  sounds  may  be  diminished  or  absent  over 
the  affected  side  and  exaggerated  over  the  healthy  portions  of  the 
lung.  Where  the  effusion  is  small  and  the  larger  bronchi  remain  open 
for  the  respiratory  current  of  air,  we  may  hear  distant  bronchial 
breathing.  In  rare  eases,  especially  in  tuberculous  pleuritic  effusion, 
the  respiratory  murmur  may  simulate  cavernous  breathing  and  lead 
to  errors  in  diagnosis,  especially  if  the  bronchophony  over  the  com- 
pressed lung  is  transmitted  along  the  pleuritic  adhesions  or  the  chest 
wall. 

Percussion. — Dulness  or  flatness,  corresponding  to  the  amount  of 
pleuritic  thickening  or  effusion,  over  the  affected  portion  of  the  lung, 
and  often  tympanitic  resonance  over  the  retracted  lung  tissue.  Per- 
cussion must  be  performed  lightly;  for  in  the  presence  of  only  a  thin 
layer  of  fluid,  forced  percussio*!  may  elicit  the  normal  resonance  of 
the  underlying  lung.  The  sense  of  resistance  to  the  finger  is  greatly 
increa.sed.     Displacement  of  the  neighboring  organs. 


DISEASES    OF    THE   RESPIRATORY    SYSTEM 


329 


Grocco's  sign  (paraverte])ral  triangle  of  dulness  on  the  side  opposite 
to  that  of  the  effusion)  is  rarely  elicited  in  young  children,  but  is  of 
diagnostic  value  if  found. 

Roentgen-Ray  Examination. — In  the  majority  of  instances  an  x-ray 
examination  aids  greatly  in  localizing  the  fluid  in  the  thoracic  cavity, 
especially  Avhen  the  effusion  is  scant}^  and  encapsulated  or  is  located 
under  the  diaphragm    (subphrenic  abscess).     In   this  connection   it   is 


Fig.  75. — Grocco's  sign  of  pleurisy  with  effusion   (paravertebral  triangle  of  dulness 
on  the  side  opposite  to  that  of  the  effusion — G). 


important  not  to  interpret  the  shadow  of  gas  in  the  upper  gastro- 
intestinal tract  as  fluid  in  the  thoracic  cavity. 

With  the  establishment  of  the  presence  of  a  pleuritic  effusion  by 
means  of  the  aforementioned  physical  signs,  the  nature  of  the  pleu- 
ral fluid  content  still  remains  to  be  determined.  In  the  majority  of 
instances  this  can  readily  be  accomplished  by  means  of  exploratory 
puncture. 

Except  where  the  exudate  is  buried  behind  a  thick  pleural  mem- 


330  DISEASES   OF   CHILDREN 

brane  or,  more  rarely,  behind  tumors  of  the  chest  wall  (so  that  the 
needle  does  not  reach  the  fluid),  or  "where  the  pleural  content  is  too 
thick  to  pass  through  the  needle,  exploratory  puncture  of  a  pleural 
effusion  usually  reveals  any  of  the  following  fluids  :  serum,  serum  with 
blood,  serum  with  pus,  pure  pus,  or  chyle.  In  accordance  with  these 
findings,  it  is  customary  to  distinguish  serous  or  serofibrinous  pleurisy, 
hemorrhagic  pleurisy,  purulent  pleurisy  (empyema,  i)yothorax),  and 
chylothorax. 

Serous  or  Serofibrinous  Pleurisy 

The  onset  may  be  sudden  with  vomiting,  chills,  rise  of  temperature 
and  pain  in  the  side,  or,  more  frequently,  insidious, — either  as  a  pri- 
mary disease  with  general  malaise,  short  cough,  increasing  dyspnea 
and  pallor,  or  as  a  secondary  affection,  with  accentuation  of  the  symp- 
toms of  the  primary  disease.  In  acute  pleurisies  the  fever  may  be 
moderately  high  and  persist  for  from  two  to  three  weeks,  and  then 
gradually  subside,  even  though  the  effusion  remains.  Bilateral  pleu- 
risy is  almost  always  tuberculous.  Pleurisy,  associated  with  pericar- 
dial or  peritoneal  symptoms,  points  to  its  tuberculous  character.  In 
young  children  with  a  yielding  thorax,  absorption  of  large  effusions 
is,  as  stated,  almost  always  associated  with  contraction  of  the  affected 
half  of  the  chest.  The  ribs  become  pressed  together,  the  intercostal 
spaces  narrowed,  the  shoulder  blade  is  drawn  nearer  the  vertebral  col- 
umn, and  the  latter  is  curved  (scoliosis).  With  complete  recovery 
from  the  disease,  the  deformity  may  in  some  cases  gradually  disappear. 
In  the  majority  of  instances,  dulness  and  suppressed  respiratory  mur- 
mur continue  as  a  result  of  pleuritic  thickening. 

The  prognosis  of  this  form  of  pleurisy,  except  that  due  to  tubercu- 
losis, is  generally  favorable.  Occasionally  acute  pleurisy  terminates 
fatally  either  as  a  result  of  a  sudden  excessive  effusion,  or  of  pulmo- 
nary edema,  embolism  of  the  pulmonalis  or  of  a  cerebral  vessel. 

Hemorrhagic  and  Tuberculous  Pleurisies 

In  the  recent  epidemic  of  influenza  quite  a  number  of  children  pre- 
sented a  hemorrhagic  exudation  in  the  pleural  cavity,  in  connection 
with  bronchopneumonia.  In  one  case,  a  boy  nine  years  old,  we  aspi- 
rated over  two  quarts  of  hemorrhagic  fluid  Avhich  showed  the  strep- 
tococcus hemolyticus  in  pure  culture.  The  patient  succumbed  to  the 
disease  within  a  week  notwithstanding  early  thoracotomy  and  the  ad- 
ministration of  autogenous  vaccine. 

Protracted  cases  of  pleurisy  should  always  be  looked  upon  with  sus- 
picion.   In  very  many  instances  they  are  of  tuberculous  nature.    This 


DISEASES   OF    THE   RESPIRATORY    SYSTEM  331 

is  particularly  true  of  bilateral  pleurisy  and  of  that  with  prolonged 
irregular  temperature  and  serohemorrhagic  exudation.  It  is  well  to 
remember,  however,  that  a  hemorrhagic  effusion  is  sometimes  ob- 
served in  scorbutic  children,  and  that  puncture  of  a  blood  vessel  or  in- 
jury to  the  diaphragm  or  liver  may  bring  forth  blood  in  the  aspirat- 
ing syringe.  In  tuberculous  pleurisy,  before  long,  other  symptoms  of 
tuberculosis  make  their  appearance.  The  presence  of  the  tubercle 
bacillus  in  the  exudate,  or,  if  the  lungs  are  involved,  in  the  sputum, 
and  a  positive  tuberculin  test  settle  the  diagnosis. 

Purulent  Pleurisy  (Empyema,  Pyothorax) 

Owing  to  the  frequency  of  pneumonias  (the  principal  cause  of  pleu- 
ritic etfusions)  in  children,  empyema  is  of  very  common  occurrence. 
In  the  majority  of  instances  the  exudation  is  purulent  from  the  be- 
ginning, more  rarely  it  is  serous  at  first,  and,  after  a  protracted  course, 
undergoes  suppurative  transformation,  as  a  result  of  an  endogenous 
infection  by  the  pneumococcus,  streptococcus,  staphylococcus,  or  the 
tubercle  bacillus.  Pyothorax  is  usually  unilateral,  and  localized  on 
the  left  side  more  frequently  than  on  the  right.  Occasionally  it  is 
bilateral,  e.  g.,  in  sepsis,  pyema,  etc.  Still  more  rarely  it  is  multilocular, 
encysted,  or  interlobular.  The  amount  of  pus  varies  from  a  few  tea- 
spoonfuls  to  a  quart.  The  exudate  may  on  the  first  puncture  prove  to 
be  seropurulent ;  but,  as  the  disease  advances,  the  purulent  character  in- 
creases, becoming  greenish-yellow  in  color  and  sometimes  fetid  in  odor. 
It  may  be  feculent,  indicating  some  connection  with  the  abdominal  con- 
tents. 

Pyothorax  may  also  develop  primarily  as  a  result  of  trauma.  As 
a  rule,  however,  it  is  met  secondarily  to  inflammatory,  especially  sup- 
purative, processes  of  the  thoracic  and  abdominal  organs,  of  the  joints, 
ribs  and  vertebra,  or  in  association  with  general  sepsis.  As  a  sequal 
or  complication  of  thoracic  or  abdominal  diseases,  empyema  usually 
sets  in  very  insidiously,  and  may  even  remain  latent  for  some  time  until 
either  the  effusion  is  so  large  as  to  cause  bulging  of  the  affected  side 
of  the  chest,  or  to  be  discovered  accidentally  during  a  routine  examination 
for  some  other  ailment.  The  onset  is  more  acute  in  cases  due  to 
trauma,  necrosis  of  the  neighboring  bony  structures,  exanthematous 
diseases,  or  in  sudden  rupture  into  the  pleural  cavity  of  abscesses  of  the 
neighboring  organs  {e.g.,  hepatic,  perinephritic,  etc.).  In  such  cases 
the  symptoms  resemble  those  of  acute  serofibrinous  pleurisy,  except 
that  the  temperature  is  higher  and  more  irregular  and  emaciation 
and  exhaustion  are  more  pronounced. 


332 


DISEASES   OF    CHILDREN 


Aside  from  the  physical  signs  already  enumerated,  empyema  com- 
plicating pneumonia  may  generally  be  suspected  where  resolution  is 
delayed  and  the  temperature  eontinues  high  and  irregular  and  is  ac- 
companied by  sweating.  In  such  cases,  even  in  the  absence  of  pathog- 
nomonic physical  signs,  Roentgen-ray.  examination  and  exploratory 
puncture  should  not  be  long  delayed. 


Fig.  76. — Extensive  right  empyema  in  a  child  four  years  old. 


With  early  operative  treatment  empyema  in  children  usually  ter- 
minates in  recovery.  If  let  alone,  the  abscess  may  rupture  sponta- 
neously either  in  the  lungs  or  externally  through  the  chest  wall — empy- 
ema necessitatis.  The  point  of  external  rupture  is  usually  found  in 
the  vicinity  of  the  sternum,  where  the  chest  wall  offers  least  resist- 
ance.    If  the  rupture  is  into  a  bronchus,  a  very  large  expectoration  of 


DISEASES    OF    THE    RESPIRATORY    SYSTEM  333 

pus  occurs  suddenly.  In  these  cases  there  is  always  dano:er  of  pyo- 
pneumothorax. In  another  "rroup  of  cases  the  pus  may  by  inspissation 
lead  to  caseous  residues  and  to  fatal  issue  from  <jradual  exhaustion 
or  from  complications,  such  as  tuberculosis,  amyloid  degeneration, 
etc. 

Chylous  Pleuritis  (Chylothorax) 

Genuine  chylous  effusion  in  the  thorax  is  an  exceedingly  rare  con- 
dition. More  frequently'  we  meet  with  other  milky  effusions, — chyli- 
form,  latescent  (nonchylous).  True  chylous  effusion  is  the  result  of 
injury  or  obstruction  of  the  thoracic  duet,  allowing  the  escape  of  chyle 
either  directly  through  an  opening  in  the  wall  of  the  duct  or  indirectly 
by  transudation. 

The  differential  diagnosis  between  the  different  varieties  of  pleurisy 
can  readily  be  made  by  means  of  an  exploratory  puncture,  and  by 
chemic,  bacteriologic,  and  microscopic  examinations  of  the  fluid  obtained. 
Bilateral  (usually  tuberculous)  pleurisy  may  be  confounded  Avith  hy- 
drothorax.  The  latter  condition,  however,  is  associated  with  anasarca, 
consecutive  to  heart  or  kidney  disease,  and  generally  runs  an  afeb- 
rile course.  Left-sided  pleurisy  may  be  differentiated  from  pericar- 
ditis by  the  absence  of  heart  symptoms  (triangular  heart  dulness) 
in  the  former,  and  of  lung  symptoms  in  the  latter.  The  synchro- 
nous occurrence  of  both  of  these  diseases,  however,  should  be  borne 
in  mind.  Right-sided,  purulent  pleurisy  may  be  mistaken  for  an 
abscess  or  hydatid  cyst  of  the  liver.  Careful  examination  will  elicit 
the  following  differential  points:  in  liver  affections  the  midaxillary 
line  forms  the  highest  point  of  dulness ;  there  are  fluctuation,  local 
tenderness  and  icterus ;  in  pleurisy  with  effusion  the  last-named  signs 
are  absent  and  the  midaxillary  line  forms  the  lowest  point  of  dulness. 
Furthermore,  in  pleurisy  aspiration  brings  forth  serum,  blood  or  pus : 
in  hydatid  cyst  of  the  liver,  a  nonalbuminous  fluid  with  ''booklets." 

The  differentiation  between  lobar  pneumonia  and  pleurisy  is  not 
always  easy,  since  both  diseases  often  coexist.  In  the  latter  event,  how- 
ever, exploratory  puncture  will  readily  clear  up  the  diagnosis. 

Pneumonia  Pleurisy  with  Effusion 

Dulness    (late).  Flatness   (early). 

Temperature  high.  Low  (in  absence  of  pus). 

Pulse-respiration  ratio  j^reatly  disturbed.  Not  so. 

Bronchial   breathing,   bronchophony.  Suppressed  breathing. 

Vocal  fremitus  and  resonance  increased.  Diminished. 

Treatment. — During  the  acute  stage,  keep  the  patient  in  bed.  Limit 
the   supply  of  fluids   (in  older  children  a  semisolid  diet,   consisting 


334  DISEASES   OP   CHILDREN 

principally  of  cereals,  concentrated  broths,  beef  juice,  soft-boiled  eggs, 
etc.).  Relieve  pain  by  salicylates,  perhaps  with  some  opiate  internally; 
by  strapping  of  the  chest;  flaxseed  poultices,  or  the  following  oint- 
ment 

Tr.  lodini 

01.  GaulthcriaG 

01.  Terebinthas 

Guaiacolis 

Ichthyolis  aa.  3  i  4.0 

Liq.  Vasdini  q.  s.  ad  f  B  ii  60.0 

M. 

S. — Paint  the  affected  parts  twice  a  day,  cover  with  absorbent 
cotton  and  bandage. 

Should  the  exudation  increase  to  such  an  extent  as  to  greatly  inter- 
fere with  breathing,  aspirate  with  Potain's  aspirator  and  follow  it 
up  with  the  local  application  and  strapping,  and  the  administration 
of  sodium  iodide  and  infusion  digitalis — the  iodide  to  promote  absorp- 
tion of  the  fluid,  the  digitalis  to  counteract  the  interference  with  the 
heart  action  by  the  exudate,  as  well  as  to  stimulate  diuresis.  These 
latter  procedures  (except  aspiration)  are  indicated  also  in  cases  run- 
ning a  protracted  course,  even  without  a  large  effusion.  Aspiration 
should  be  practised  in  tuberculous  pleurisy  only  to  relieve  the  res- 
piratory difficulty,  and  in  ehylothorax,  both  as  a  palliative  as  well  as 
a  curative  measure. 

As  soon  as  pyothorax  is  detected,  an  immediate  operation  for  re- 
moval of  the  pus  is  imperative.  To  wait  for  eventual  spontaneous 
evacuation  of  the  pus  through  the  lungs  or  externally,  is  hazardous, 
principally  because  of  the  supervening,  often  fatal,  exhaustion,  and 
of  the  danger  of  complicating  pyopneumothorax,  an  incurable  fistula, 
or  caseous  degeneration.  It  is  to  be  noted,  however,  that  in  acutely 
developing  influenza  empyema  aspiration  is  to  be  preferred  to  thorac- 
otomy until  the  active  pulmonary  inflammation  has  subsided.  In  tuber- 
culous empyema,  surgical  interference  is  indicated  only  in  threatening 
suffocation,  or  grave  cardiac  embarrassment.  Empyema  of  brief  dura- 
tion with  readily  flowing  pus  usually  does  well  with  a  free  incision 
into  one  of  the  intercostal  spaces  and  good  drainage.  On  the  other 
hand,  cases  of  long  standing  or  those  with  inspissated  pus  should  be 
treated  by  resection  of  a  rib,  in  order  to  permit  free  escape  of  the  pus. 
The  disfigurement  after  such  operation  in  children  is  comparatively 
slight,  and  many  cases  of  regeneration  of  even  several  ribs  are  on 
record.  If  the  empyema  is  bilateral,  it  is  advisable  to  operate  at  sepa- 
rate sittings. 


DISEASES   OF    THE   RESPIRATORY    SYSTEM 


335 


Fig.  77. — Same  case  as  Fig.  76  three  weeks  later  after  resection  of  second  and  third 
ribs.     Note  clearing  of  right  lung. 

Patients  recovering  from  pleurisy,  with  or  without  effusion,  should 
have  plenty  of  outdoor  air,  preferably  in  the  country,  seashore,  or 
mountains.  Older  children  will  derive  great  benefit  from  horseback 
riding.  For  expansion  of  the  retracted  lung  after  a  protracted  at- 
tack of  pleurisy  with  effusion,  systematic  breathing  exercises  and  cold 
sponging  of  the  chest  or  cold  affusions  are  very  useful. 


336 


DISEASES    OF    CHILDREN 


Fig.   78. — Same  case  as  Fig.   76  two  months  later.     Eight  lung  field  almost   clear. 
Note  retraction  of  chest  wail  and  secondary  scoliosis. 


The  importance  of  wholesome  feeding  should  not  be  underestimated. 
Iron,  the  hypophosphites,  cod  liver  oil,  and  extract  of  malt  are  helpful 
to  effect  the  cure. 

Prompt  attention  to  suppurative  foci  {e.g.,  necrosis  of  ribs  or  ver- 
tebrae) and  early  treatment  of  pneumonia  by  fresh  air  will  frequently 
prevent  empyema. 


DISEASES    OF    THE    RESPIRATORY    SYSTEM 


337 


Asthma 

The  pathogenesis  of  asthma  in  children  is  essentially  the  same  as 
that  in  adults — stenosis  of  the  lumen  of  the  bronchial  tubes.  The 
stenosis  may  be  brought  about  either  by  a  spasmodic  contraction  of 
the  muscle  fibers  of  the  bronchioles,  or  by  vasomotor  turgescence  and 
swelling  of  the  bronchial  mucosa.  Children  suffering  from  asthma 
usually  present  an  hereditary  tendency  toward  the  disease,  a  suscepti- 
bility to  protracted  irritations  of  the  nasopharyngeal,  laryngeal,  and 
bronchial  mucous  membranes  (exudative  diathesis,  q.  v.,)  or  a  history 
of  pertussis,  bronchopneumonia  or  chronic  bronchitis.  In  many  instances 
local  causes,  such  as  adenoids,  deformities  of  the  nasopharynx,  persistent 
thymus,  etc.,  are  met  with,  and  some  cases  are  traceable  to  reflex  causes, 
e.g.,  indigestion  (see  "Allergy,"  p.  87).  Asthma  in  young  children 
seems  also  to  be  correlated  to  eczema.  In  one  marked  case  (two-year- 
old  baby)  under  my  observation,  recurrence  of  the  asthmatic  attack 
coincided  regularly  with  the  subsidence  or  marked  improvement  of  the 
eczematous  eruption.  Symptomatic  asthma  is  occasionally  based  upon 
hay  fever — resulting  from  the  action  of  pollen  of  certain  plants  upon 
the  mucous  membrane  of  the  nasopharynx — and,  finally,  an  asthmatic 
attack  is  sometimes  a  manifestation  of  hysteria. 


Classification  of  Causes  of  Bhonchial  Asthma. 

BRONCHIAL    ASTHMA     (WALKKR) 


NO.    SENSITIVE   TO 

02 
'A 
O 

C3   W 

%> 

PROTEIN    IN 

^ 

■< 

^ 

H 

<) 

W    CO 

w  w 

W    H 

w  e 

< 

5 

^ 

< 

03  <; 

o  < 

M    S 

^    'Tn 

w 

K 

Ph 

a  " 

u 

n  'S. 

cc 

S  a 

Q 

H 

iJ 

H 

o 

K 

S    'A 

03    >5 

i-t  i-t 

O 

O 

iJ 

O 

B  ^ 

W    fc 

P  w 

W    W 

^  ^ 

o 

-!l 

O 

«!< 

a  o 

0-    O 

y<  M 

O,    W 

<  W 

b 

Da 

a< 

Under 

tw 

0  years.  . 

34 

9.0 

28 

83 

19 

23 

5 

15 

Between 

2- 

-  5.. 

30 

7.5 

27 

90 

14 

9 

2 

G 

( < 

5- 

-10.. 

37 

9.0 

15 

40 

12 

5 

2 

15 

<< 

10- 

-15.. 

35 

9.0 

24 

70 

6 

5 

5 

13 

Sensitive 

Not 

sensitive 

to  proteins 

to  proteins 

Asthma 

throughoul 

Seasonal 

Asthma 

throng 

lOUt 

Seasonal 

the 

year 

asthma 

the  year 

asthma 

due 


to 


due 


to 


due 


to 


due 


to 


(animals 
food 
bacteria 


pollens 


bacteria 


bacteria 


338  DISEASES   OF    CHILDREN 

With  these  etiologic  factors  in  view,  the  subdivision  of  asthma  into 
true  and  false  is  quite  justified.  Clinically  the  two  varieties  differ  in 
that  genuine  asthma  is  invariably  associated  with  chronic  bronchial 
catarrh,  hence,  is  based  upon  a  pathologic  entity,  and  is  of  longer  dura- 
tion than  false  asthma.  There  is  nothing  characteristic  about  the  ca- 
tarrh. The  paroxysm  usually  comes  on  at  night.  The  child  coughs, 
is  a  little  wheezy,  and  in  a  few  hours  the  typical  attack  is  in  full  sway. 
The  latter  consists  of  extreme  dyspnea,  inspiratory  as  well  as  expira- 
tory, anxious  expression  of  the  face,  congested  eyes,  cyanosis  or  pallor, 
cold  extremities,  restlessness  and  prostration.  The  patient  is  usually 
relieved  by  sitting  up  in  bed.  Auscultation  of  the  chest  reveals  sonor- 
ous and  sibilant  rales,  wheezing,  squeaking,  and  whistling  respiration. 
These  sounds  are  often  audible  at  a  distance.  As  the  attack  subsides 
the  breathing  becomes  less  and  less  noisy,  less  labored,  and  less  rapid. 

There  may  be  complete  apyrexia,  or  a  rise  of  temperature  of  from 
two  to  three  degrees.  The  respiratory  rate  may  be  anywhere  from  40 
to  80  and  the  pulse  150  or  over.  During  the  height  of  the  paroxysm 
there  is  marked  eosinophilia,  and  where  expectoration  is  abundant 
Curschman's  spirals  and  Charcot-Leyden 's  crystals  are  found  in  the 
more  or  less  glairy  mucus.  Toward  the  end  of  the  attack  the  thorax  may 
appear  barrel-shaped;  but  unless  the  asthma  is  chronic  in  nature  and 
characterized  by  prolonged  attacks,  the  emphysematous  deformity  of 
the  chest  is  usually  only  temporary.  The  attack  may  last  minutes,  hours, 
or  days,  with  temporary  remissions,  but  after  abatement  of  the  paroxysm 
the  child  is  apparently  in  good  health  except  for  the  bronchial  catarrh. 
In  genuine  asthma,  exacerbations  usually  occur  in  the  fall  and  spring, 
when  the  sudden  atmospheric  changes  contribute  to  catarrh  of  the  mu- 
cous membrane  of  the  respiratory  tract.  On  the  other  hand,  paroxysms 
of  false,  spasmodic  asthma  may  occur  at  any  time  when  the  exciting 
cause,  e.  g.,  indigestion,  sudden  fright,  etc.,  presents  itself. 

As  a  rule,  asthma  is  not  fatal  per  se.  Delicate  infants,  however,  may 
succumb  during  a  severe  attack,  as  a  result  of  suffocation,  or  after  fre- 
quently repeated  attacks,  as  a  result  of  emphysema,  cardiac  dilatation, 
or  even  cerebral  hemorrhage. 

Treatment. — The  importance  of  curing  the  disease  at  its  very  in- 
ception or,  at  least,  preventing  or  mitigating  the  paroxysm,  is  obvious. 
A  cure  can  be  effected,  if  the  cause  can  be  found  and  corrected.  At- 
tention to  abnormalities  of  the  nose  and  throat  is  especially  fruitful 
in  this  direction.  Children  having  an  asthmatic  or  arthritic  history 
should  be  given  particular  care  in  the  way  of  preventing  colds  and 
coughs,  overfeeding,  exposure  to  unhealthy  surroundings,  miasmatic 


DISEASES   OF    THE   RESPIRATORY   SYSTEM  *       339 

affections,  undue  excitement,  etc.  An  attack  may,  in  a  way,  be  aborted 
by  early  administration,  preferably  hypodermically,  of  atropine,  1/2000 
grain  and  morphine  1/60  grain  or  adrenalin  (5  to  10  minims),  and 
by  apomorphine  1/50  to  1/100  grain,  repeated,  if  necessary,  after  half 
an  hour.  The  latter  drug  is  especially  efficient  in  "dyspeptic"  or 
"hysterical"  asthma.  A  few  drops  of  a  suprarenal  gland  solution  in- 
stilled several  times  a  day  into  the  nose  sometimes  act  admirably.  If 
the  paroxysm  continues  we  may  resort  to  the  following  combination : 

1}     Potassii  Bromidi  3  ss  2.00 

Tr.  Hyoscyami 

Ext.  Aspidospermae  (Quebracho) 
Ext.  Grindeliae  Eobustse  aa  f  3  i  4.00 

Syr.  Pruni  Virginianae  q.  s.  ad  f  5  ii  60.00 

M. 
S. — One  teaspoonful  every  three  hours;  for  a 
child  five  years  okl. 

A  course  of  syrup  of  the  iodide  of  iron  with  cod  liver  oil  is  very 
useful  in  all  eases,  and  change  of  climate,  to  the  seashore  or  inland, 
is  sometimes  effective  in  enhancing  a  permanent  cure.  In  protracted 
cases  a  meat  and  milk-free  diet  may  be  tried.  The  patient  is  fed  ex- 
clusively on  well-cooked  cereals — without  milk  or  sugar — and  vege- 
tables.   Sweet  butter  is  added  to  make  the  food  more  palatable. 

In  treating  asthma  we  should  always  bear  in  mind  that  asthma-like 
attacks  are  observed  as  a  manifestation  of  a  large  thymus,  spasmo- 
philia, malaria,  or  heart  and  kidney  disease,  calling  for  specific  thera- 
peutic measures  to  remedy  the  underlying  affections. 

Emphysema  Pulmonmn 

Abnormal  distention  of  the  lungs  with  air  occurs  as  a  result  of 
forced  inspiration,  e.  g.,  in  stenosis  of  the  larynx  (croup)  or  bronchioles 
(asthma),  whooping  cough,  in  bronchitis  or  bronchopneumonia  with 
violent  coughing,  etc.,  or  from  forcible  expiration,  e.  g.,  cornet  playing. 
Owing  to  the  great  elasticity  of  the  puerile  lung  and  its  tendency  to  rapid 
adjustment,  emphysema  as  a  permanent  affection  is  rarely  observed  in 
children.  If  it  does  occur,  it  is  most  frequently  limited  to  the  apices 
and  the  anterior  borders  of  the  lungs.  Exceptionally  the  emphysema  is 
disseminated  throughout  the  entire  lung.  In  this  event  the  symptoms 
are  practically  the  same  as  those  in  the  adult — namely,  exaggerated 
resonance  on  percussion,  diminution  of  relative  cardiac  dulness,  dyspnea, 


340  DISEASES   OF    CHILDREN 

fulness  of  the  upper  portion  of  tliorax  or  barrel-shaped  chest,  and  pro- 
longed incomplete  expiration.  In  cases  of  long  standing  there  is  con- 
secutive involvement  of  the  heart — usually  dilatation  of  the  right  heart, 
with  or  without  hypertrophy. 

The  treatment  consists,  in  addition  to  removal  of  the  cause  cliiefly  of 
change  of  air   (mountains),  and  light  breathing  exercises. 

Bronchiectasis 

Bronchial  dilatation  is  not  very  uncommon  in  children,  but  as  it 
usually  forms  a  sequel  of  respiratory  diseases  (unresolved  pneumonia) 
with  violent  coughing,  or  aspiration  of  foreign  bodies  into  a  bronchus, 
its  presence  is  frequently  obscured  by  the  symptomatology  of  the 
preceding  affection.    Cases  of  congenital  bronchiectasis  are  on  record. 

The  dilatation  of  the  bronchus  may  be  cylindrical  or  sacculated, 
and  is  almost  always  associated  with  peribronchial  sclerosis  (pul- 
monary contraction),  and  occasionally  with  emphysema. 

There  are  no  pathognomonic  signs  of  this  affection,  except,  perhaps, 
the  copious  morning  expectoration  of  greenish-yellow,  often  fetid, 
purulent  mucus,  which  on  standing  separates  into  an  upper  layer  of 
serum  and  a  lower  of  pus.  Auscultation  of  the  affected  part  of  the 
chest  reveals  abundant  moist  rales,  and,  if  the  bronchiectatic  cavities 
lie  near  the  chest  wall,  cavernous  signs,  which  greatly  resemble  those 
of  tuberculous  cavities.  In  bronchiectasis,  however,  the  sputum  is 
free  from  tubercle  bacilli  and  the  course  is  usually  afebrile  and  often 
remittent — the  child  often  doing  well  for  wrecks.  In  cases  of  long 
standing,  there  is  usually  clubbing  of  the  fingers  and  deformity  of  the 
chest.  An  extensive  bronchiectasis  may  often  be  revealed  by  a  roentgen- 
ray  picture. 

Treatment. — Relative  recoveries  from  this  affection  have  been  re- 
ported particularly  recently  by  surgeons  who  do  not  hesitate  to  per- 
form pneumonectomy.  Otherwise  the  majority  of  cases  are  incurable, 
and  after  a  shorter  or  longer  (years)  course  the  patients  succumb 
to  intercurrent  diseases,  such  as  pneumonia,  miliary  tuberculosis,  or 
pulmonary  gangrene. 

The  medical  treatment  is  principally  hygienic  and  prophylactic: 
wholesome  food,  tonics,  breathing  exercises,  inhalation  of  warm  va- 
pors with  eucalyptus,  creosote,  or  turpentine,  or  of  oxygen,  residence  in 
a  high,  dry  region. 

To  facilitate  emptying  the  dilated  bronchi  of  their  mucopurulent 
content,  gentle  inversion  of  the  little  patient  a  few  times  a  day  proves 
useful. 


DISEASES    OF    THE   RESPIRATORY    SYSTEM 


341 


Pulmonary  Gangrene 

Gangrene  of  the  lungs  is  not  rarely  a  sequel  of  pneumonia,  phthisis, 
grave    exanthematous    diseases,    gangrenous   processes   of    the    mucous 


Fig.   79. — Pneumothorax   (posterior  view).     Note  compression  of  lungs  and  disloca- 
tion of  heart. 


membrane  or  of  the  skin,  foreign  bodies  in  the  air  passages  (entrance 
of  bits  of  food),  etc.     The   symptomatology  of  this  affection  is  ill 


342 


DISEASES   OF   CHILDREN 


defined.  In  older  children,  as  in  adults,  the  macro-  and  miero-scopic 
appearances  of  the  expectoration  (upper  layer,  mucopurulent;  middle, 
serous;  lower,  almost  wholly  of  pus;  remnants  of  lung  tissue  and  plugs 
containing  needles  of  fat,  acids  and  detritus)  are  very  helpful  in  the 
diagnosis.  On  the  other  hand,  in  infants,  chief  reliance  must  be  placed 
upon  the  general  cachectic  condition  of  the  patient,  the  coexistence  of 
gangrene  of  the  mouth,  throat  or  vulva,  the  frequent  occurrence  of 


Fig.  80. — Pneumoliypoderma  (emphysema  cutis)  in  a  girl  five  years  old  complicating 

measles  with  pneumonia. 

hemoptysis  (absence  of  tubercle  bacilli),  fetid  diarrhea,  and  foul  breath. 
The  cough  is  usually  spasmodic. 

The  course  of  the  disease  is  comparatively  rapid,  fatal  termination 
usually  occurring  within  a  few  weeks,  either  from  gradual  loss  of 
strength  or  from  complications,  such  as  hemoptysis,  pneumothorax, 
thrombosis,  or  cerebral  abscess. 

The  treatment  is  symptomatic — tonics,  inhalation  of  antiseptics,  and, 
if  the  gangrenous  process  is  accessible,  surgical  intervention. 


DISEASES    OP    THE   RESPIRATORY    SYSTEM 


343 


Pneumothorax,  Hemopneumothorax,  Pyopneumothorax 

These  conditions  occur  principally  as  a  result  of  traumatism  (frac- 
ture of  a  rib  or  clavicle),  laceration  of  the  lungs  from  violent  cough- 
ing or  by  foreign  bodies,  perforation  of  the  lungs  through  empyema, 
gangrene  and  similar  destructive  processes. 

The  symptomatology  is  the  same  as  in  adults:  sudden  severe  dysp- 
nea, bulging  of  the  affected  side,  tympanitic  percussion  sounds.  When 
effusion  occurs,  there  is  hyperresonance  over  the  upper  portion  of  the 


Fig.  81. — Same  case  as  Fig.  80  six  weeks  later, 

affected  part  of  the  chest  above  the  line  of  effusion  and  dulness  or  flat- 
ness over  the  seat  of  effusion.  Succussion  gives  rise  to  splashing 
sounds.  The  diagnosis  can  readily  be  corroborated  by  thoracentesis  and 
Roentgenograms. 

The  treatment  consists  of  the  administration  of  opiates  for  the  pain 
and  aspiration  (of  air  or  fluid)  to  relieve  the  intense  dyspnea  in  addi- 
tion to  attention  to  the  primary  cause. 


344  DISEASES   OF    CHILDREN 

Pneumohypoderma* 

(Emphysema  Cutis) 

Entrance  of  air  into  the  subcutaneous  areolar  tissue  ordinarily  results 
from  rupture  or  laceration  of  the  pulmonary  alveoli  or  bronchi  during 
violent  coughing  or  dyspnea  {e.g.,  in  pertussis,  measles,  phthisis  pul- 
monum),  or  secondarily  to  suppurative  or  caseous  processes  in  the  lungs. 
It  is  occasionally  observed  in  connection  with  traumatic  pneumothorax, 
and  after  tracheotomy  and  intubation.  The  air  inflation  may  remain 
limited  to  the  neck  and  face  or  spread  over  the  entire  upper  half  of 
the  body,  and  exceptionally  also  to  the  lower  half. 

Pneumohypoderma  can  be  detected  by  the  distinct  crackling  or  purr- 
ing sensation  imparted  to  the  examining  finger,  and  can  readily  be  dif- 
ferentiated from  anasarca  by  the  absence  of  pitting  on  pressure.  In 
severe  cases  the  distention  of  the  skin  imparts  to  the  palpating  finger  the 
sensation  very  much  akin  to  that  experienced  when  pressing  upon  a 
tensely  inflated  toy  balloon. 

If  the  immediate  cause  can  be  promptly  arrested,  e.g.,  violent  cough, 
by  means  of  morphine,  reabsorption  of  the  air  usually  occurs  within  a 
few  weeks.    Rapidly  fatal  cases,  however,  are  on  record. 


*The  new  term   is  suggested   because  it  locates  the   exact  seat  of  the  trouble;    it  also   helps  to 
distinguish   this   condition  from   "surgical   emphysema,"   which   is   produced  \>y  gasogenic   bacteria. 


CHAPTER  VII 

SPECIFIC  COMMUNICABLE  DISEASES 

Influenza 
(The  Grip,  The  Flu,  Spanish  Influenza) 

Influenza  is  an  acute,  highly  communicable,  endemic  and  epidemic 
disease,  characterized  by  a  variable  group  of  respiratory,  gastric  and 
nervous  phenomena,  intense  prostration  and  great  tendency  to  grave 
complications  and  sequelae. 

Until  the  most  recent  epidemic,  the  bacillus  of  Pfeiffer  was  looked 
upon  as  the  indisputable  cause  of  this  affection;  since  then,  however, 
a  great  deal  of  evidence  to  the  contrary  has  accumulated,  Avhich  sheds 
doubt  on  its  specificity.  Col.  Victor  C.  Vaughan,  whose  scientific  and 
practical  experience  with  the  grip  epidemic  has  been  almost  unlimited, 
does  not  hesitate  to  state  that  to  him  the  evidence  that  the  Pfeiffer 
bacillus  as  the  cause  of  influenza  is  not  at  all  convincing  for  the  fol- 
lowing reasons.*  "In  the  first  place,  it  is  by  no  means  constantly  found 
in  influenza  or  its  sequelae.  In  the  second  place,  it  is  often  even  Avith 
greater  frequency  found  in  other  diseases  than  it  is  in  influenza.  In 
the  third  place,  influenza  is  characterized  by  a  marked  leucopenia, 
whereas  injection  of  the  Pfeiffer  bacillus  causes  a  leucocytosis — just 
the  opposite!"  Moreover,  repeated  experiments  to  communicate  the 
disease  by  direct  inoculation  (subcutaneously,  by  the  nose  and  throat 
and  swallowing  of  influenza  sputum)  proved  negative.  On  the  other 
hand,  some  authorities  maintain  that  the  influenza  bacillus  is  demon- 
strable in  the  majority  of  cases  of  influenza,  but  that  it  plays  an  un- 
important part  in  the  secondary,  so  often  fatal,  infections,  the  latter 
developing  chiefly  as  the  result  of  a  characteristic  violent  reduction 
of  the  resisting  power  of  the  tissues,  which  offer  the  pneumococci, 
streptococci  (hemolyticus  and  viridans),  Friedlander  bacillus,  staphy- 
lococcus aureus  and  micrococcus  catarrhalis  a  favorable  culture  me- 
dium to  become  markedly  pathogenic! 


•Jour.   Am.   Med.   Assn.,   Dec.   21,    1918. 

tUacteriologic  exaiiiination  of  the  pleural  fluid  removed  surgically  and  sent  to  the  laboratory 
together  with  that  encountered  at  necropsy,  revealed  streptococci  in  most  instances,  occasionally 
Staphylococcus  aureus  and  pneumococci.  Racteriologic  examination  of  the  pus  in  the  intra- 
pulmonary  abscesses  almost  invariably  yielded  a  pure  growth  of  Streptococcus  hemolyticus,  but 
occasionally  Staphylococcus  aureus.  In  three  cases,  Streptococcus  hemolyticus  was  isolated  in 
pure  culture  from  the  blood.  In  the  i)neumonic  exudates  themselves,  the  prevailing  microorgan- 
ism was  a  streptococcus.  In  occasional  instances,  influenza  bacilli  and  pneumococci  were  iso- 
lated  in   combination   with   one   another   or   with    streptococci.      There   were   three   cases   in   which 

345 


346 


DISEASES   OF    CHILDREN 


The  pathology  of  the  disease  differs  with  every  epidemic  as  well  as 
with  each  individual  attack.  In  cases  of  moderate  severity  the  lining 
membrane  of  the  rhinopharynx  and  lower  portions  of  the  respiratory 
tract  are  hyperemic  and  sparingly  covered  by  a  grayish,  often  very  thick, 
deposit.  The  bronchi  and  bronchioles  are  filled  with  a  mucopurulent 
secretion  containing  the  aforementioned  bacteria.  Here  and  there  the 
pulmonary  alveoli  are  involved.  In  severe  cases  the  inflammation  ex- 
tends throughout  the  entire  lung  and  pleura.     In  the  recent  epidemic 


Fig.  82. — Section  of  lung  of  epidemic  influenza  in  a  young  infant  showing  conges- 
tion of  the  blood  vessels  in  the  pleura  and  hemorrhages  just  beneath  the  pleural  sur- 
face.     (Drs.  Martha  Wollstein  and  A.  Goldbloom.) 


of  the  so-called  Spanish  influenza,  Oberndorfer,*  among  many  other 
clinicians  and  pathologists,  found  the  following  pathologic  entity: 


massive  portions  of  a  lobe  were  consolidated  in  such  fashion  as  to  resemble  ordinary  croupous 
pneumonia.  In  all  of  these  the  exudate  was  sticky.  In  two,  Bacillus  tnucosiis-caj'snlatus  was 
isolated,  in  the  other  Strcjytococcus  mucosus.  In  three  other  cases,  streptococci  were  isolated 
from  the  blood  during  life;  and  all  of  them,  at  necropsy,  presented  abscesses  of  the  lungs. 
(Symmers,   Dimerstein  and  Frost,  Jour.  Am.   Med.   Assn.,  July,   1920.) 

*Ueber     die     Pathologische     Anatomic     der     Influenzaartigen     Epidemic     (Miinchen.     med. 
Wchnschr.,  Vol.   Ixv,  p.  810). 


SPECIFIC    COMMUNICABLE   DISEASES  347 

In  tlic  initial  stage  of  the  affection  of  the  lungs,  namely,  when  only  small  foci 
■without  any  great  reaction  in  the  immediate  neighljorhood  are  observed,  the  most 
striking  findings  were  small,  bean-sized  hemorrhages  projecting  into  the  lung  tissue. 
As  a  next  step  there  followed  a  firmer  intiltration  of  the  parenchyma,  the  nodules 
sitting  subpleurally  and  raising  the  pleura  in  consequence.  A  whole  scale  of  inter- 
mediate formations  lay  between  these  small  nodules  and  large  hemorrhagic  tuberous 
infiltrations;  all  possible  gradations  were  observed  from  simple  blood  extravasa- 
tions into  the  lung  tissue,  still  containing  air,  to  firm,  almost  dry,  infarct-like  hem- 
orrhages of  a  bluish-black  tinge.  These  extensive  infiltrations  were  of  the  same  shape 
as  the  usual  pulmonary  hemorrhagic  infarcts,  namely,  they  had  the  form  of  a  wedge 
with  its  base  resting  on  the  pleura,  thus  clearly  indicating  an  intimate  relationship 
with  the  vascular  system  of  the  lungs.  In  this  purely  hemorrhagic  initial  stage  no 
thrombi  were  ever  found  in  these  arteries,  the  extravasation  of  red  cells  being  ob- 
viously due  to  an  abnormal  permeability  of  certain  portions  of  the  arterial  system. 

The  second  stage  was  characterized  by  exudative  pneumonic  processes  combined 
with  hemorrhages.  The  picture  varied  considerably  at  times.  There  may  be  a 
true  croupous  hepatization  of  lobular,  or  even  lobar,  extent,  both  red  and  gray, 
though  the  tinge  was  usually  brownish  and  not  as  a  rule  very  distinct.  These  pneu- 
monic infiltrations  usually  embraced  in  their  center  circumscribed  hemorrhages. 
The  surface  on  section  was  not  dry,  being  covered  by  a  slimy,  dirty  coating,  thus 
resembling  a  picture  of  Friedlander 's  pneumonia.  The  pneumonic  foci  were  some- 
times flattened  out  at  the  ends  into  yellowish  white  wedge-shaped  strictures  corre- 
sponding to  anemic  infarcts  both  in  form  and  color.  These  often  became  the  seat 
of  gangrene  or  suppuration,  the  pleura  also  being  obviously  involved  in  the  process. 
In  the  majority  of  cases  it  was  a  catarrhal  and  desquamative  succulent  infiltration 
rather  than  a  fibrinous  exudation,  but  qlmost  always  severely  complicated  by  sup- 
puration. 

The  bronchi  were  filled  with  pus  already  in  the  first  stage,  the  smaller  branches 
containing  thin  fluid,  though  at  times  dried-up  exudates  formed  firm  plugs  occlud- 
ing the  lumen  of  the  bronchioli.  This  purulent  bronchitis  had  as  its  consequence  an 
extensive  bronchiectasis  with  the  bronchi  distended  cylindrically.  The  bronchi  and 
their  blood  vessels  were  often  surrounded  by  purulent  infiltrations  originating  from 
the  lymphatic  system.  In  other  cases,  again,  there  were  seen  on  section  enormous 
numbers  of  minute  abscesses  surrounded  by  hemorrhages,  the  suppuration  being  ob- 
viously hematogenic  in  origin.  These  minute  abscesses  often  became  confluent, 
thus  ending  up  by  the  formation  of  large  caverns  of  pus. 

The  pleura  participated  in  the  process.  The  first  signs  consisted  in  punctiform 
hemorrhages,  or  ecchymoses;  serous  exudations  followed  next,  and,  as  often  as  not, 
empyemas  completed  the  picture.  As  a  rule,  one  side  only  was  affected.  Pericardi- 
tis was  a  natural  consequence  of  pleuritis.  There  were  no  gross  changes  in  the 
heart  gave  for  some  thickening  of  the  arteries  of  the  lung  hilum.  Occasionally  in- 
cipient  endocarditis  was   encountered. 

The  larynx  and  the  upper  third  of  the  trachea  showed  no  involvement  in  the 
process.  The  lower  portion,  however,  was  the  seat  of  an  intense  mucopurulent 
exudation,  which  in  many  cases  assumed  a  fibrinous  character,  with  the  consequent 
formation  of  extensive  pseudomembranes  in  the  lower  trachea  and  down  into  the 
bronchi.     Sometimes  edema  of  the  epiglottis  was  observed. 

A  striking  feature  was  presented  by  the  hyperplastic  condition  of  the  lymphatic 
apparatus  of  the  tongue  and  the  tracheal  ring.  The  thymus  was  well  preserved, 
the  cervical  and  axillary,  but  not  the  inguinal,  glands  were  enlarged. 


348 


DISEASES   OF   CHILDREN 


In  the  postmortem  examination  of  18  infants,  Drs.  Wollstein  and 
Goldbloom*  found  also  subcapsular  hemorrhages  over  the  thymus,  thy- 
roid and  suprarenals,  and  also  small  hemorrhages  within  the  swollen 
bronchial  and  mediastinal  lymph  nodes. 

The  alimentary  tract  rarely  escapes  infection  especially  in  young 
children.  The  spleen  is  enlarged,  sometimes  a  septic  spleen  tumor  be- 
ing found.  The  liver  is  but  seldom  involved.  The  kidneys  show  a 
general  hyperemia.     In  the  brain  and  the  meninges  there  is  marked 


Fig.  83. — Section  of  lung  of  epidemic  influenza  in  a  young  infant  showing  sup- 
purative bronchitis  and  areas  of  pneumonia  about  the  bronchi.  The  exudate  is 
chiefly  polynuclear  in  character.      (Drs.  Martha  Wollstein  and  A.  Goldbloom.) 


vasodilatation,  but  no  meningitis.  Punctiform  hemorrhages  are  met 
in  dilTerent  parts  of  the  encephalon,  and  cases  are  on  record  in  which 
the  ventricles  were  filled  with  blood  and  pus.  There  are  also  hemor- 
rhages in  the  heart  valves,  with  a  consequent  displacement  of  the 
fibers  and  damage  to  the  endothelium;  thus,  no  definite  endocarditis. 


"Am.  Jour.    Dis.    Children,   March,    1919. 


SPECIFIC    COMMUNICABLE   DISEASES  349 

but  lesions  which  facilitate  the  development  of  a  secondary  micotic 
endocarditis. 

The  essence  of  the  whole  pathologic  picture  consists,  therefore,  in 
the  abundance  of  hemorrhages  seen  in  the  mucous  and  serous  mem- 
branes, in  the  respiratory  tract,  and  in  the  lungs,  which  indicate  a 
damaged  condition  of  the  capillary  vascular  system.  The  whole  process 
seems  to  be  primarily  a  bacteremia  localized  in  particular  in  the  pul- 
monary blood  vessels.  From  a  purely  anatomic  point  of  view  the  con- 
dition bears  many  points  of  resemblance  with  pneumonic  plague, 
though  there  is  no  indication  as  to  an  entry  of  the  virus  through  defi- 
nite h^mphatic  channels.  Furthermore,  as  already  stated,  the  true 
nature  of  the  virus,  the  primary  infecting  agent,  is  still  undiscovered. 

Clinical  Course. — ^No  age  is  exempt  from  this  affection,  and  one  at- 
tack neither  predisposes  nor  immunizes  for  any  length  of  time  against 
another  one.  The  incubation  period  varies  from  two  to  five  days. 
The  onset  is  usually  sudden  or  may  be  preceded  by  a  few  mild  prodro- 
mata  common  to  all  febrile  affections.  The  previous  attempts  to  clas- 
sify the  grip  into  three  distinct  types, — namely,  catarrhal,  gastric, 
and  nervous,  was  based  upon  an  erroneous  conception  of  the  pathology 
of  the  disease.  It  is  the  multiplicity  of  the  lesions  and  the  complexity 
of  the  symptoms  which  are  the  characteristics  of  influenza.  Thus,  the 
child  sneezes,  coughs,  has  no  appetite,  vomits,  complains  of  pain  in 
the  entire  body,  especially  in  the  throat,  head,  eyes  and  lower  extremi- 
ties, has  high  fever,  is  very  restless  or  lies  exhausted  in  a  semistupor 
— an  indefinite  group  of  symptoms  which  is  met  with  in  quite  a  num- 
ber of  acute  febrile  affections. 

The  onset  is  usually  sudden,  sometimes  preceded  by  signs  of  fatigue, 
headache,  and  chilliness.  This  is  followed  by  an  abrupt  rise  of  tem- 
perature up  to  104°  F.  or  higher,  which  usually  continues  during  the 
entire  course  of  the  disease.  The  throat  is  deep  red  in  color,  and  the 
tonsils  and  fauces  are  often  covered  with  glairy  mucus  and  occasion- 
ally with  a  yellowish-white  irregular  deposit.  The  cough  is  dry,  harsh 
and  painful,  especially  over  the  region  of  the  sternum,  and  large,  soft 
or  dry  sibilant  rales  are  heard  over  the  greater  portion  of  the  thorax. 
In  infants  particularly,  there  are  more  or  less  pronounced  manifesta- 
tions also  of  the  alimentary  tract.  The  baby  vomits,  refuses  food,  cries 
from  abdominal  pain,  and  has  an  increased  number  of  foul  smelling, 
variously  colored,  thin  evacuations.  In  older  children  the  gastroin- 
testinal symptoms  are  usually  limited  to  anorexia,  tympanites  and 
occasionally  constipation.  The  nervous  system  is  almost  invariably 
implicated  in  the  grippel, process.  Among  the  characteristic  nervous 
phenomena  we  may  mention,  in  the  order  of  their  frequency,  hyper- 


350 


DISEASES   OF    CHILDREN 


esthesia,  headache,  somnolence,  insomnia,  vertigo,  and  convulsions.  The 
child  cries  when  it  is  being  lifted  or  moved  al)out  in  bed.  The  pain 
in  the  head,  neck,  trunk  and  extremities  often  keeps  the  little  pa- 
tient in  a  position  closely  resembling  opisthotonos,  and  if  accompanied 
by  convulsions,  one  is  often  tempted  to  diagnose  the  symptom  complex 
as  meningitis.  The  somnolence  is  frequently  profound.  One  baby  un- 
der observation  dozed  for  six  days,  awakening  with  a  fit  of  crying 
when  disturbed  even  for  nursing.  On  the  other  hand,  some  children 
keep  awake  for  several  days  in  succession,  notwithstanding  the  admin- 
istration of  hypnotics.  Vertigo  in  infants  usually  escapes  our  notice; 
in  those  able  to  hold  up  their  heads,  it  is  manifested  by  the  latter 
dropping  forward   or  swaying  in  dilTerent   directions.     The   eyelids 


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Fig.  84. — Fever  curve  of  atypical  influenza  in  a  baby  fourteen  months  old. 

droop,  the  face  turns  pale  and  vomiting  supervenes.  Older  children 
invariably  complain  of  this  miserable  feeling,  and  find  difficulty  in 
holding  their  heads  erect. 

The  blood  shows  a  striking  leucopenia,  even  in  the  presence  of  com- 
plicating pneumonia.  According  to  L.  A.  Conner,  a  leucopenia  of  from 
2,000  to  3,000  white  blood  cells  per  cubic  millimeter  is  by  no  means 
uncommon.  Leukocyte  counts  were  made  by  Montgomery  and  Dunham* 
in  thirty  cases  of  influenza  occurring  in  infants  and  children  less  than 
12  years  of  age.     They  found  that  the  tendency  in  uncomplicated  in- 


'Am.  Jour.  Dis.  Child.  Vol.  18,  No.   3. 


SPECIFIC    COMMUNICABLE   DISEASES 

'  r.     . 


LfE 


351 


fluenza  in  infants  and  children  is  toward  a  leukopenia, ,  rather  than  a 
leukocytosis.  There  is  a  tendency  to  a  slight  leukocytosis  in  compli- 
cating pneumonia.  In  this  series,  in  all  j^neumonia  cases  resulting 
fatally,  the  leukocyte  counts  were  under  10,000.  The  prognosis,  in 
general,  is  better  in  pneumonia  cases  which  exhibit  a  leukocytosis. 
Differential  counts   have   shown:    (a)    a  tremendous  variation   in   the 


Fig.  85. — Paralysis  of  N.  abduceiis,  with  convergent  strabismus  and  facial  paralysis 
following  postinfluenzal  encephalitis.     Her  mentality  remained  greatly  affected. 


differential  formula,  and  (&)  nothing  sufficiently  constant  to  be  of  clini- 
cal aid  in  diagnosis  or  prognosis. 

Influenza  shows  a  peculiar  predilection  for  hemorrhagic  processes, 
such  as  epistaxis,  hemorrhage  from  the  bowels,  in  the  skin,  the  ears 
and  pleural  cavity,  and  in  the  urinary  tract.  In  a  contribution  to  the 
study  of  this  disease  (N.  Y.  Med.  Jour.,  June  30,  1900),  I  called  atten- 
tion to  the  concurrence  of  hemorrhagic  encephalitis  during  the  course 
of  the  grip,  and  have  since  had  occasion  to  observe  several  such  cases. 
This  form  of  encephalitis  seems  to  be  identical  with  the  so-called  leth- 


3^    V  S    !,  S  b  1  ^  DISEASI':S   OF    CHILDREN 

■I  t/A^l  0  ?^  T  c  0    ^0   ?i?3JJ00 

/,  ,^  t^p.^rgic  ^iiceph^]|i.t,i^.X.sei^  J).  624)  so  frequently  noted  during  the  recent 
influenza  epidemic  and  thereafter.  One  boy,  eight  years  old,  under  my 
care,  died  from  this  complication  twelve  hours  after  its  onset.  As  a 
rule,  the  mortality  in  these  cases  is  rather  low.  Of  8  cases  recorded  by 
H.  Ileiman^  none  died  but  2  of  them  remained  imbeciles.  Similar  cases 
were  recorded  by  me-  sevel'al  years  ago. 

In  uncomplicated  sporadic  cases  the  tendency  of  influenza  is  toward 
rapid  convalescence  and  recovery,  especially  in  strong  eliildren  and  those 
free  from  hereditary  and  acquired  encumbrances.  Unfortunately,  how- 
ever, influenza,  by  reducing  the  power  of  resistance  of  the  patient,  predis- 
poses to  prolific,  often  fatal,  complications.  In  some  epidemics  ear  affec- 
tions predominate,  in  others  cerebrospinal  disorders,  and  in  others  again, 
as  it  happened  in  the  last  epidemic,  respiratory  affections  devastate  the 
world.  The  so-called  ' '  influenza  pneumonia ' '  usually  sets  in  the  second  or 
third  day  of  the  disease,  at  a  time  when  the  influenza  proper  seems  on  the 
wane.  The  patient,  especially  if  an  infant,  begins  to  vomit  again,  and 
shows  definite  signs  of  being  ill  at  ease,  without  being  able  to  locate  the 
seat  of  his  discomfort.  The  cough  loosens,  but  the  dyspnea  increases  and 
the  heart  beat,  as  a  rule,  slows  down  and  gives  the  impression  of  being 
more  steady  in  quality.  At  this  stage  careful  phj'sical  examination 
of  the  thorax  often  utterly  fails  to  elicit  any  signs  of  pneumonia,  ex- 
cept, perhaps,  exaggerated  breathing  over  the  posterior  portions  of 
the  lower  lobes.  On  many  occasions  I  was  most  painfully  surprised 
to  find  what  at  first  seemed  to  be  a  simple  bronchitis,  within  but  a  few 
hours  transformed  into  double  fatal  pneumonia.  Similar  to  erysipelas 
of  the  skin,  the  inflammatory  process  of  influenza  seems  rapidly  to 
spread  by  contiguity  from  structure  to  structure  and  from  one  organ 
to  the  other,  so  that  on  every  examination  of  the  patient  a  newly  dis- 
eased focus  is  detected.  Cyanosis,*  delirium  and  coma  generally  pre- 
cede the  fatal  issue,  which  usually  takes  place  within  three  to  five 
days.  Those  children  who  withstand  the  exhausting  effects  of  the 
violent  acute  stage  often  survive,  even  though  convalescence  and  re- 
covery may  very  frequently  be  markedly  delayed  by  additional  grave 
complications  and  sequel£e.  As  already  stated,  the  pleura  very  rarely 
escapes  involvement.  The  pleuritic  effusion  is  not  infrequently  hemor- 
rhagic or  purulent  in  character  from  the  start  and  accumulates  in  the 
thorax  with  extraordinary  rapidity.  In  an  infant  ten  months  old 
the  left  side  of  the  chest  was  filled  with  pus  on  the  sixth  day  after 

lAm.  Jour.  Dis.   Child.,  August,  1919. 

-H.   B.   Sheffield,   "The  Backward  Baby,"  p.   72. 

*The  cyanosis  is  caused  by  an  abnormally  high  oxygen  unsaturation  of  the  blood,  which  mav 
be  Droduced  either  by  an  admixture  of  reduced  hemoglobin  and  oxyhemoglobin  in  the  superficial 
capillaries,  or  by  an  incomi)lere  oxidation  of  the  venous  blood  in  the  lungs.  (W.  C.  Stadie, 
New   York,   and   C.    Lundsgaard,   Copenhagen.     Jour.    Exp.   Med.,   \'ol.   30,    No.    3.) 


SPECIFIC    COMMUNICABLE   DISEASES  353 

the  onset  of  the  influenza.  Otitis  is  very  common  during  the  early 
catarrhal  stage  of  the  disease.  In  the  majority  of  instances  the  inflam- 
mation clears  up  without  suppuration,  but  as  already  mentioned,  in 
some  epidemics  the  ear  infection  is  most  virulent,  sometimes  termi- 
nating in  mastoiditis  simultaneously  with  the  early  appearance  of  con- 
gestion of  the  tympanum.  Nephritis  (often  hemorhagic)  and  pyelo- 
cystitis  form  an  early  or  late  complication.  In  malignant  cases  the 
peritoneum,  pericardium  and  meninges  are  attacked  in  rapid  succes- 
sion, in  fact,  as  we  are  here  dealing  with  a  general  bacteremia,  no 
organ  of  the  body  is  spared;  hence  it  is  of  little  consequence,  from  a 
therapeutic  point  of  view,  where  the  infection  begins  and  where  it 
ends.  Among  the  milder  complications  and  sequelae  we  may  mention 
cardiac  neuroses  (bradycardia  and  tachycardia),  neuralgia,  neuritis, 
arthritis,  adenitis,  parotitis,  conjunctivitis,  inflammation  of  the  acces- 
sory sinuses,  and  occasionally  periostitis.  Similar  to  measles,  influenza 
predisposes  to  tuberculosis,  and  in  a  number  of  instances  divers  psy- 
choses were  noted  to  follow  the  disease,  sometimes  several  weeks  after 
apparent  recovery. 

Finally,  every  form  of  cutaneous  eruption  may  accompany  influenza. 
At  times  the  eruption  is  bright  red  and  punctiform,  resembling  that 
of  scarlatina,  or  roseolar  or  pustular  in  character  which  may  readily 
be  mistaken  for  rubeola  or  varicella.  Urticaria  is  not  uncommon, 
and  simple  erythema  may  be  seen  in  the  majority  of  cases  at  some 
stage  of  the  affection.  The  peculiar  facial  flush  ("lobster  face")  often 
noted  in  adults,  is  very  rarely  observed  in  children.  The  hemorrhages 
in  the  skin  may  assume  the  appearance  of  purpura  hemorrhagica. 

The  diagnosis  of  influenza  is  comparatively  easy  during  its  preva- 
lence in  epidemic  form,  but  quite  the  reverse  otherwise.  "Colds"  and 
gastrointestinal  disorders  being  of  such  ordinary  occurrence  in  children 
that  influenza  is  generally  not  thought  of  when  such  manifestations 
present  themselves.  Furthermore,  the  diagnosis  is  often  obscured  by 
the  numerous  complications.  For  general  guidance  in  the  diagnosis 
we  may  state  that  the  simultaneous  development  of  respiratory,  diges- 
tive and  nervous  phenomena,  leucopenia  and  marked  prostration  should 
always  arouse  our  suspicion,  even  in  the  absence  of  an  epidemic  of  in- 
fluenza. I  ■ 

As  already  emphasized  the  prognosis  varies  greatly  with  each  epi- 
demic, and  the  mortality  may  range  anywhere  between  10  and  30  per 
cent.  Of  course,  the  outcome  of  the  disease  depends  entirely  upon  the 
number  and  severity  of  the  complications. 

Treatment. — Influenza  is  always  to  be  looked  upon  as  a  treacherous 
and  dangerous  disease,  however  mild  its  appearance  in  its  early  stages ; 


354  DISEASES   OF   CHILDREN 

and  appreciating  the  fact  that  it  is  so  highly  communicahle  and  so 
grave  in  its  consequences,  it  is  obvious  that  every  effort  must  be  made 
to  arrest  the  disease  at  its  source  by  strict  isolation  of  the  patient, 
and  to  employ  every  means  to  prevent  the  grave  complications  and 
sequelae.  During  the  recent  epidemic  an  attempt  was  made  to  attain 
these  objects  in  view  by  prophylactic  vaccination.  In  order  to  avoid 
burdensome  repetition  and  controversies  of  different  clinicians,  we 
shall  take  the  liberty  of  citing  the  views  of  G.  W.  McCoy,^  Director, 
Hygienic  Laboratory,  U.  S.  Public  Health  Service,  which  embody  the 
consensus  of  opinion  of  the  profession  as  a  whole. 

Vaccine  from  Influenza  Bacillus  as  a  Prophylactic 

In  discussing  this  sul^ject,  we  will  give  attention,  first,  to  the  results  obtained 
from  the  use  of  a  vaccine  made  from  the  influenza  bacillus  alone,  or  from  other 
suspected  etiologic  agent,  which  aims,  to  be  sure,  to  prevent  the  primary  disease, 
and  later  to  a  review  of  the  evidence  with  respect  to  vaccine?  which  liave  been 
devised  with  the  special  object  of  preventing  the  development  of  pneumonia  or  of 
mitigating  its  severity. 

A  vaccine  made  from  the  influenza  bacillus  alone  seems  not  to  liave  ajipealed 
sufficiently  to  European  workers  to  induce  them  to  try  it  when  the  epidemic  pre- 
vailed abroad.  In  this  country,  its  use  has  been  confined  largely  to  New  England. 
The  early  reports  on  this  vaccine  were  very  encouraging;  figures  were  presented 
which,  if  taken  at  their  face  value,  Avould  convince  any  one  of  the  efficiency  of  the 
agent ;  but,  when  these  figures  were  submitted  to  careful  analysis,  much  doubt 
remained  as  to  whether  the  vaccine  was  of  any  service  whatsoever.  The  chief  source 
of  error  lay  in  the  fact  that  the  inoculations  had  been  done  during  the  progress  of 
the  epidemic,  and  that  the  case  incidence  among  the  vaccinated  was  compared  with 
the  case  incidence  in  the  general  population  or  in  the  control  groups  from  the  be- 
ginning of  the  epidemic.  Now,  it  is  plain  that  if,  after  the  epidemic  is  well  under 
way,  we  vaccinate  a  portion  of  the  persons  in  a  population,  the  percentage  of  per- 
sons attacked  will  be  smaller  among  the  vaccinated  than  among  the  nonvaecinated, 
because  a  percentage  of  the  total  number  of  cases  will  have  occurred  before  the 
vaccine  is  given.  Not  only  does  this  introduce  an  error  by  counting  in  the  control,  or 
nonvaecinated  group,  cases  that  have  occurred,  early,  but  also  it  leaves  a  select 
group  to  be  vaccinated,  wholly  or  in  part,  in  which  the  percentage  of  susceptibles 
is  smaller  than  in  the  original  group  of  which  they  formed  a  part. 

To  make  this  clear,  let  us  suppose  that  ten  days  after  an  epidemic  started  in  5. 
population  of  1,000  persons,  an  admittedly  worthless  vaccine  was  administered  to 
one  half  of  those  who  at  that  time  remained  unattacked  by  the  disease.  Let  us 
further  assume  that  on  the  date  of  vaccination  20  per  cent  of  the  population 
had  sickened,  leaving  800  well  persons,  of  whom  400  were  vaccinated.  Since  the 
hypothetical  vaccine  is  worthless,  the  morbidity  will  be  as  great  in  the  vaccinated 
as  in  the  nonvaecinated  group.  Let  us  assume  this  to  be  an  additional  20  per  cent. 
Then  the  total  morbidity  in  the  vaccinated  group  will  be  20  per  cent  of  400,  or 
eighty   cases.     The   total   morbidity    in   the   unvaccinated,   however,    if    we   consider 


ijour.  A.  M.  A,  Aug.  9,  1919. 


SPECIFIC    COMMUNICABLE   DISEASES  355 

the  entire  period  of  tlie  epidemic  -will  be  20  ])er  cent  of  1,000,  or  200,  plus  20  per  cent 
of  400,  or  eighty,  -whicli  would  make  280  cases. 

Although  the  error  is  now  sufficiently  clear,  we  have  seen  reports  which,  on  the 
basis  of  the  above  figures,  if  ai)plied  to  this  hypothetical  worthless  vaccine,  make 
it  appear  to  be  a  valuable  prophylactic.  The  statement  of  these  reports  would  be, 
in  effect,  that  one  half  of  the  population  was  vaccinated,  that  among  the  vaccinated 
only  eighty  cases  developed,  wliile  among  the  unvaccinated  280  cases  appeared. 
Hence  the  obvious  value  of  the  vaccine. 

We  must  also  rememljcr  that  a  vaccine  can  scarcely  be  expected  to  exert  any 
appreciable  prophylactic  effect  before  from  seven  to  ten  days  after  the  vaccine  is 
given,  since  a  week  or  more  is  required  for  immunity  to  develop.  A  comparison  is 
fair  which  considers,  among  both  vaccinated  and  nonvaccinated,  only  cases  that 
have  occurred,  say,  ten  days  or  more  after  the  vaccinations  are  made. 

When  the  influenza  bacillus  vaccine  was  submitted  to  such  critical  tests  as  the 
inoculation  of  approximately  half  of  the  individuals  in  institutions,  or  in  other  large 
groups,  its  failure  became  apparent.  A  few  examples  of  this  are  worth  citing. 
Hinton  and  Kane  were  able  to  vaccinate  about  half  of  the  patients  at  an  epileptic 
colony  long  enough  before  the  disease  became  prevalent  in  the  institution  to  justify 
the  drawing  of  conclusions  from  their  data.  The  vaccine  used  contained  800,000,- 
000  organisms  per  mil,  and  a  total  of  2,000,000,000  were  administered  to  each  per- 
son.    The  results  were  as  shown  in  Tal)le  1. 

Table  1. — Effect  of  Influenza  Bacillus  Vaccine  as  a  Prophylactic 

NOT  vaccinated 

vaccinated  (controls) 

NO.     per  cent  no.  per  cent 

Number  of  persons   461  ....  518  .... 

Cases  of  influenza 163         .35.4  178         34.3 

Deaths    28         17.0  24         13.5 

On  the  basis  of  this  experiment  the  authors  reach  the  obvious  conclusion  that  the 
vaccine  was  Avithout  value. 

A  similar  test  was  made  on  the  naval  personnel  at  Felham  Bay  Training  Station ; 
here  a  part  of  the  individuals  of  a  group  were  vaccinated,  the  remainder  being  held 
as  controls.  According  to  the  latest  available  report,  9  per  cent  of  the  554  inocu- 
lated persons  developed  the  disease,  and  5  per  cent  of  the  800  who  had  not  been  inoc- 
ulated developed  it. 

Similar  failure  attended  the  attempts  at  immunization  of  men  at  the  naval  base 
at  Paris  Island,  S.  C.  It  was  definitely  shown  that  neither  incidence  nor  severity 
was  influenced  by  the  vaccination.  These  observations  were  all  on  groups  large 
enough  to  make  the  deductions  of  value. 

A  number  of  controlled  vaccinations,  in  which  influenza  bacillus  vaccine  Avas 
used,  carried  out  in  institutions  by  the  Public  Health  Service,  gave  the  rather  para- 
doxical result  of  showing  an  increased  percentage  of  attacks  among  the  vaccinated, 
but  more  deaths  among  the  nonvaccinated.  This  result  was  obtained  with  a  vaccine 
directed  against  the  primary  disease,  not  against  the  complicating  pneumonia.  The 
results  are  shown  in  Table  2.  These  figures  illustrate  tlie  fallacy  of  giving  much 
weight  to  the  results  of  a  small  set  of  observations  in  work  of  this  sort. 


356  DISEASES    OF    CHILDREN 

Table  2. — Eesults  Obtained  by  Influenza  Bacillus  Vaccine  in  Institutions 

not  vaccinated 
vaccinated  (controls) 

NO.     PER   CENT  ^q     pg^    CENT 

Number  of  persons    484  ....  842         .... 

Cases  of  influenza   153         31.6  223         26.4 

Deaths    , 0         ....  4  1.8 

VACCINES  FEOM  STREPTOCOCCUS  AND  OTHER  ORGANISMS 

Another  series  of  vaccinations  aimed  directly  against  the  supposed  causative 
agent  was  that  reported  by  Ely,  Lloyd,  Hitchcock  and  Nickson.  These  workers 
believed  that  the  epidemic  was  due  primarily  to  a  hemolytic  streptococcus  which 
could  be  detected  in  the  blood  and  in  the  lungs.  From  the  fact  that  the  organisms 
with  which  these  observers  worked  soon  lost  their  chain-forming  properties  and,  in 
some  instances,  the  power  to  hemolyze  promptly,  they  express  some  doubt  as  to 
whether  they  should  be  classed  as  streptococci,  and  they  further  assume  that  there 
are  material  differences  between  different  strains.  The  results  of  the  use  of  a 
vaccine  prepared  from  organisms  isolated  from  the  cases  Avere  apparently  most 
encouraging,  though  none  of  the  experiments  was  controlled  in  a  manner  that  would 
definitely  establish  the  value  of  the  preparation.  The  work  of  these  observers  needs 
to  be  repeated  before  the  results  can  be  accepted  for  general  application. 

When  we  come  to  consider  the  evidence  with  respect  to  the  vaccines  especially 
designed  to  prevent  the  pneumonic  complications  of  influenza,  we  find  again  such  con- 
flicting reports  that  one  is  somewhat  bewildered. 

The  only  papers  from  a  foreign  source  that  have  come  to  my  notice  are  those  by 
Eyre  and  Lowe,  who  used  a  mixed  vaccine  which  contained  the  pneumococcus,  the 
streptococcus,  the  influenza  bacillus,  Staphylococcus  aureus,  Micrococcus  catarrhalis, 
B.  pneumonia  and  B.  septus. 

These  authors  believe,  and  indeed  present  rather  convincing  figures  in  their  first 
paper  to  prove  their  point,  that  the  use  of  this  vaccine  produces  lowered  resistance, 
which  may  last  for  "from  a  few  hours  to  two  or  three  weeks,"  during  which  period 
the  incidence  of  respiratory  infections  would  be  increased  among  inoculated  groups. 

The  early  experience  of  the  English  authors  does  not  refer  directly  to  the  pro- 
phylaxis of  influenza,  but  it  is  cited  here  to  show  that  there  may  be  an  element  of 
danger  in  the  indiscriminate  use  of  vaccines  in  the  presence  of  a  rapidly  spreading 
epidemic  like  influenza  in  which  naturally  many  persons  in  the  "negative  phase" 
would  be  attacked. 

In  a  later  paper,  the  same  writers  report  on  the  experience  with  vaccine  in  the 
epidemic  in  England  in  the  autumn  of  1918.  Stress  is  laid  on  the  necessity  of 
preparing  a  vaccine  from  cultures  but  recently  isolated. 

The  figures  given  and  the  facts  presented  by  these  writers  are  difficult  of  inter- 
pretation and  permit  of  almost  any  conclusion  that  one  wishes  to  draw  from  them, 
from  the  optimistic  one  that  fatalities  after  influenza  occur  only  among  the  non- 
vaccinated,  to  the  pessimistic  one  that  fatalities  occur  only  among  the  vaccinated, 
though  the  authors  believe  the  results  were  good.  They  frankly  reiterate  the  opin- 
ion that  for  a  short  time  following  vaccination  there  is  an  increased  incidence  among 
the  vaccinated,  owing  to  temporarily  increased  susceptibility,  but  the  writers  con- 
sider that  this  risk  is  justified  by  the  benefit  that  they  believe  may  accrue  later.  As 
inoculations  were  performed  largely  dqring  the  prevalence  of  the  epidemic,  and  as 


SPECIFIC    COMMUNICABLE   DISEASES  357 

the  controls  a])ix'ar  to  include  persons  who  developed  tlie  disease  prior  to  the  vac- 
cination, the  alleged  good  results  may  be  misleading. 

THE  POLYVALENT  VACCINE  OF  EOSENOW 

Eosenow  prepared  a  mixed,  and,  at  least  in  part,  polyvalent,  vaccine  from  the 
various  fixed  types  of  pneumococci,  pneumococci  of  Group  IV,  hemolytic  streptococci. 
Staphylococcus  aureus  and  the  influenza  bacillus,  all  of  whicli  had  bet-n  recently 
isolated.  This  vaccine  was  adjusted  to  meet  the  bacterial  flora  encountered  during 
the  ei)idemic;  thus,  in  a  manner  it  may  be  said  that  it  was  designed  to  approach  an 
autogenous  vaccine,  but  was  intended  primarily  for  prophylactic  purposes.  Dr. 
Eosenow  felt  that  this  vaccine  should  be  prepared  for  use  in  any  community  from 
the  strains  of  organisms  there  prevailing,  and  that  a  vaccine  adjusted  to  meet  the 
needs  of  one  locality  might  not  meet  those  of  another.  The  figures  given  for  pro- 
tection are  encouraging,  but  do  not  lend  themselves  to  critical  analysis. 

Vaccine  prepared  in  the  manner  suggested  by  Dr.  Eosenow  should  theoretically 
have  a  better  chance  for  success  than  those  we  shall  next  consider,  but  the  practical 
difficulties  of  preparing  it  from  locally  prevailing  strains  and  adjusting  it  to  meet 
the  changing  flora  of  the  respiratory  tract  in  a  disease  that  spreads  as  rapidly  as 
influenza  are  obvious. 

A  specimen  of  the  vaccine  which  was  being  used  in  Illinois  was  tried  in  Cali- 
fornia, under  rigidly  controlled  conditions,  without  success.  The  disease  did  not 
appear  in  the  institution  where  the  test  Avas  made  until  eleven  days  after  the  last 
injection,  but,  after  the  epidemic  had  swept  through  it,  the  results  revealed  that 
37  per  cent  of  the  vaccinated  were  attacked,  against  28  per  cent  of  the  controls, 
while  4.5  per  cent  of  the  vaccinated  population  died,  against  3.6  per  cent  of  the 
nonvaccinated.  These  are  differences  too  small  to  be  significant.  Tests  made  in 
other  institutions  gave  similar  results,  though  we  need  not  take  the  time  to  con- 
sider the  details  here. 

The  only  report  we  have  on  a  vaccine  directed  against  the  influenzal  pneumonias 
associated  with  the  fixed  fypes  of  the  pneumococcus  is  that  of  Cecil  and  Vaughan, 
whose  work  was  conducted  at  Camp  Wheeler  and  was  directed  primarily  against  the 
usual  pneumonias  of  the  camp.  Apparently  the  antipneumococcus  vaccine  reduced 
somewhat  the  incidence  of  influenzal  pneumonia  among  the  vaccinated,  though,  to 
use  the  author's  words,  "influenza  causes  a  marked  reduction  in  resistance  to 
pneumonia  even  among  vaccinated  men, ' '  These  authors  show  clearly  that  the  case 
mortality  of  secondary  pneumonias  was  not  reduced  by  the  vaccination,  contrary 
to  the  claim  so  often  made,  that  the  vaccine,  when  it  fails  to  protect  perfectly,  at 
least  leads  to  a  milder  type  of  the  disease.  Cecil  and  Vaughan  believe  that  the 
results  of  their  experiment  with  respect  to  pneumococcus  pneumonia  were  obscured 
by  the  influenza  epidemic;  evidence  that  the  prophylactic  action  of  the  vaccine 
employed  against  influenza  was  not  striking,  since  the  epidemic  should  have  served 
to  emphasize  rather  than  obscure  the  results  of  the  beneficial  action  of  a  really 
valuable  prophylactic  agent. 

The  general  consensus  of  opinion  of  the  profession  seems  inclined 
to  the  belief  that  prophylactic  and  therapeutic  vaccination  has  failed 
in  a  definite  manner  to  influence  either  the  morbidity  or  the  mortality 
of  influenza. 

Until  a  specific  vaccine  or  drug  against  influenza  will  be  perfected, 
we  will  be  obliged  to  treat  it  symptomatically :    the  salicylates,  with 


358  DISEASES    OF    CHILDREN 

or  without  quinine  and  phenacetin,  for  the  relief  of  temperature  and 
pain;  mild  expectorants,  with  or  without  small  doses  of  codeine,  to 
allay  the  cough;  heart  tonics,  especially  digitalis,  to  sustain  the  heart's 
action;  hydrotherapy  in  the  form  of  cool  sponging  or  warm  baths  for 
hyperpyrexia;  oxygen  for  the  dyspnea  and  cyanosis;  lumbar  puncture 
for  delirium  and  convulsions,  and  absolute  rest  in  bed  and  a  light  diet,  to 
maintain  the  patient's  vitality.  The  nose,  mouth  and  throat  should  be 
kept  clean  by  means  of  Dobell's  solution,  and  the  alimentary  tract  free 
from  putrefactive  matter  by  a  daily  intestinal  irrigation  and  mild 
laxatives.  Complications  arising  should  be  treated  according  to  in- 
dications. (See  "Pneumonia,"  ''Nephritis,"  "Peritonitis,"  "Enceph- 
alitis," etc.) 


R     Acid.  Acet.  Salicyl. 

gr.  XV 

1.00 

Caffeinae  Natrii  Bcnz. 

gr.v 

0.3 

Chocolate  et  Sacchari  q.  s 

M. 

Div.  in  pulv.  No.  viii. 

S. — One  powder  every  three 

hours,  for  a 

child 

three  years  old. 

IJ     Natrii  Salicyl. 

3ss 

2.0 

Potassii  Citratis 

3i 

4.0 

Extr.  Glycyrrhizae  Fl. 

3ii 

8.0 

Aq.  Anisi  q.  s.  ad 

f  5ii 

60.0 

3  ss 

2.0 

3  ss 

2.0 

3i 

4.0 

3  ss 

2.0 

5i 

30.0 

fSii 

60.0 

M. 

S. — One  teaspoonful  every  three  hours,  for  a 
child  three  years  old. 

R     Liq.  Animonii  Anis. 

Natrii  Benzoici 

Syr.  Ipecacuanha} 

Tr.  Digitalis 

Syr.  Altheae 

Aq.  Anisi  q.  s.  ad 

M. 
S. — One  teaspoonful  every  four  hours,  for  a 
child  three  years  old.    One-twentieth  of  a  grain 
of  codeine  may  be  added  to  each  dose  of  the 
above  medicine,  if  the  cough  is  distressing. 

Rubeola 

(MoRBiLLi,  Measles) 

Measles  is  probably  the  most  frequent  and  most  readily  communicable 
eruptive  fever  of  childhood.  Children  of  from  two  to  six  years  are 
most  susceptible  to  it,  but  it  is  not  rarely  met  with  in  older  and  younger 
ones,  and  cases  in  the  newborn  have  been  reported.    In  the  majority  of 


SPECIFIC    COMMUNICABLE   DISEASES 


359 


instances  one  attack  immunizes  the  patient  against  another  one,  numer- 
ous exceptions,  however,  are  on  record.  The  cases  of  recurrent  measles 
often  prove  to  be  rubeola  on  one  occasion,  and  rubella,  or  a  similar  skin 
eruption,  on  another.  The  disease  is  communicable  in  all  its  stages 
(particularly  the  catarrhal  stage)  by  means  of  the  as  yet  unknown  con- 
tagium* — which  dwells  in  the  lacrimal,  nasal,  and  bronchial  secretions, 
and  probably  also  in  the  papules  and  squamae — either  by  direct  contact 
or,  more  rarely,  through  intermediate  persons,  the  air,  or  fomites. 
Nine  to  fifteen  days — the  period  of  incubation — pass  after  invasion  of 
the  system  by  the  materia  morbi  without  any  characteristic  manifesta- 
tion of  ill  health,  except  slight  anorexia,  restlessness,  ephemeral  rise 
of  temperature,  etc.,  which  toward  the  end  lead  to  a  more  acute  aggra- 
vation of  the  condition  and  mark  the  beginning  of  the  prodromic  stage. 


DAY 

.  .  .Ujs|.N,M.olJ,.|„u|.U„UM».i«»|| 

TtHt 

^^iJ.i,!.i.|j.Li.|.i.Li.ULj.U.U  j.UU.  j.U.I.i.U^i.w.  .i.II 

* 

T" 

.::   !::  F:::::::  :::  ::. ::::  +  :..  ........ 

1  ■  ■ 

102* 

100 

r.:i 



::: 

1 

">_ 

444- 

Fig.  86. — Fever  curve  of  measles. 

This  stage  usually  lasts  three  days,  rarely  longer  (up  to  a  week  in  de- 
bilitated children).  The  little  patient  complains  of  chilliness,  headache, 
and  fatigue,  hangs  its  head  or  sleeps  most  of  the  time,  coughs  and  occa- 
sionally sneezes,  and  presents  a. rise  of  temperature  of  from  2°  to  4°  F. 
Not  rarely  the  fever  drops  the  next  day,  but  the  catarrhal  symptoms 
continue  in  severer  form.  Examination  of  the  mouth  and  throat  in  the 
majority  of  cases  reveals  upon  the  mucous  membranes  of  the  soft  and 
hard  palate  diffuse  redness  or  punctiform  or  stellate  spots,  and  on  the 
buccal  mucous  membrane  and  inner  surface  of  the  lips  from  six  to 
twenty,  rarely  more,  red  spots,  with  a  central,  rounded,  slightly  elevated 
bluish  efflorescence.  These  spots  never  cause  pain  or  ulcerate.  They 
are  called  Koplik  spots— the  latter  deserving  the  credit  of  having  proved 


*R  Tunnicliff  (Jour.  A.  M.  A.,  April  7,  1917)  has  discovered  a  coccus  in  the  blood  and  in 
the  nose  and  throat  in  the  verv  early  stages  of  measles.  Whether  this  coccus  is  the  primary 
cause  or  a  secondary  invader  is  still  undetermined.  Measles  has  recently  been  produced  ex- 
perimentally. 


360  DISEASES   OF    CHILDREN 

the  pathognomonic  significance  of  tlie  spots  as  an  early  sign  of  measles. 
This  enanthema  of  the  buccal  mucous  membrane  not  rarely  appears 
from  three  to  five  days  before  the  exanthema. 

Another  twenty-four  hours  and  the  eruptive  stage  is  reached.  Bright 
red,  pinhead-  to  lentil-sized  dots  appear  over  the  forehead,  about  the 
ears  and  over  the  face  (chin  and  around  the  nose  and  mouth — circum- 
oral  ring),  and  rapidly  enlarge  to  irregularly  serrated,  pea-  and  bean- 
sized,  sharply  circumscribed,  rounded  or  crescentic,  slightly  elevated 
red  spots,  which  disappear  on  pressure.  From  these  points  the  erup- 
tion rapidly  spreads,  often  in  crops,  over  the  body  and  limbs,  taking 
about  twenty-four  hours  to  complete  the  process.  At  this  time  the 
catarrhal  symptoms  also  are  at  their  height.  The  face  is  flushed  and 
edematous,  the  eyes  are  red  and  watering  and  dread  light;  the  nasal 
catarrh  is  intense,  the  cough  frequent,  harsh  and  often  barking,  the 
voice  hoarse,  the  temperature  high  (104°  F.,  or  higher),  the  urine 
scanty  and  high  colored  (diazo  reaction  often  positive)  ;  the  child  is 
drowsy,  at  times  delirious,  often  vomits  and  occasionally  suffers  from 
diarrhea  (sometimes  bloody,  especially  during  the  hot  summer  months). 
The  peripheral  and  lymphatic  glands  are  not  rarely  swollen  and  pain- 
ful, and  the  spleen  is  somewhat  enlarged. 

It  is  generally  accepted  that  cases  of  measles  in  which  the  exanthema 
appears  on  the  back  first  are  usually  grave  in  character.  The  same 
holds  true  of  the  cases  in  which  the  exanthema  suddenly  fades. 

The  eruptive  stage  lasts  from  five  to  six  days.  Toward  the  end 
of  the  stage  the  eruption  begins  to  fade,  especially  on  the  face,  and 
bran-like  scales  take  the  place  of  the  exanthema.  With  the  fading 
of  the  eruption  there  is  often  a  critical  decline  of  the  temperature 
(sometimes  preceded  by  morning  or  evening  remissions)  and  its  con- 
comitant symptoms,  except  the  bronchial  catarrh.  .  The  desquamative 
stage  lasts  about  one  week,  so  that  the  patient  is  usually  entirely  well 
by  the  end  of  the  fourth  week  from  the  time  of  infection.  Sometimes 
traces  of  the  exanthema  in  the  form  of  bluish-red  spots  remain  over 
some  portions  of  or  the  whole  body  which  do  not  disappear  on  pres- 
sure with  the  finger.     They  are  of  no  special  significance. 

Deviations  from  the  typical  course  of  the  disease  are  not  rare.  Thus, 
the  exanthema  may  be  absent  or  so  scanty  as  to  escape  observation — 
morhilli  sine  exanthema — notwithstanding  the  pronounced  character  of 
the  catarrhal  and  febrile  symptoms.  In  such  cases  the  diagnosis  from 
the  grip  is  almost  next  to  impossible,  and  can  at  best  only  be  surmised  in 
the  presence  of  an  epidemic  or  another  case  of  measles  in  the  immediate 
surroundings. 

The  eruption  may  appear  in  the  form  of  small  papules,  at  times  pene- 


PLATE  VI 


Buccal  Exaxtiiema  ix  Measles  (Koplik's  Spots) 

(Courtesy  of  Dr.  John  Zahorsky.) 


SPECIFIC    COMMUNICABLE   DISEASES  361 

trated  by  a  hair^ — morhUli  papiilosi;  or  be  covered  by  minute  vesicles — 
mortilli  miliares. 

The  appearance  of  tlie  exanthema  may  be  delayed  for  a  day  or  two 
and  then  be  localized  principally  upon  the  body  and  limbs  or  become 
confluent  so  as  to  resemble  the  rash  of  scarlatina — morhilli  scarlatinosi. 
Occasionally  small  hemorrhages  occur  between  the  spots — morhilli  hemor- 
rkagici.  This  form  of  measles  is  not  to  be  mistaken  for  morhilli  hemor- 
rhagici  maligni,  "black  measles,"  which  is  rather  very  rare  and  observed 
only  in  delicate,  cachectic  children.  In  this  condition  instead  of  the 
eruption  there  are  numerous  petechige  and  ecchymoses,  in  addition  to 
hemorrhages  from  the  nose,  ears,  genitalia,  kidneys  or  bowels.  Malig- 
nant measles  is  usually  associated  with  early  depression,  very  high 
temperature,  rapid  and  frequent  pulse,  dry,  brown  and  thickly  coated 
tongue,  sopor,  convulsions  and  coma,  and  often  ends  fatally  within 
three  days. 

Occasionally  the  temperature  is  protracted  or  after  a  fall  suddenly 
rises,  indicating  the  occurrence  or  near  advent  of  complications  or 
sequelae.  Ordinarily  complications  set  in  toward  the  end  of  the  erup- 
tive stage,  but  may  appear  as  early  as  the  prodromie  stage.  At  this 
period  also  we  are  apt  to  find  angina  tonsillaris,  epistaxis,  severe  vomit- 
ing and  diarrhea,  catarrhal  laryngitis,  pneumonia,  etc. 

In  the  eruptive  stage  pneumonia  forms  the  chief  complication.  Vio- 
lent coughing  is  prone  to  give  rise  to  laceration  of  the  lungs  and  con- 
secutive "pneumohypoderma."  (See  p.  344.)  Quite  frequently  we 
meet  also  wuth  pseudocroup  and  more  rarely  with  diphtheria.  The 
diphtheria  of  the  throat  sometimes  develops  secondarily  to  that  of  the 
conjunctiva;  more  frequently,  however,  the  former  occurs  primarily, 
and  the  diphtheritic  conjunctivitis  remains  limited  to  the  original 
focus.  It  was  my  privilege  to  see  2  cases  in  point.  One  boy,  six  years 
old,  succumbed  to  laryngeal  diphtheria  complicating  measles,  while  his 
brother,  three  years  old,  was  saved  from  blindness,  and  perhaps  death, 
by  early  administration  of  antitoxin.  The  affected  eye  presented  a 
clinical  picture  resembling  that  of  gonorrheal  ophthalmia.  The  diph- 
theritic conjunctivitis  cleared  up  entirely  witlin  ten  days,  but  was 
followed  by  typcal  diphtheritic  paralysis  of  the  throat.  Severe  stoma- 
titis is  not  uncommon,  and  numerous  cases  of  noma  {q.v.)  complicat- 
ing or  following  measles  are  on  record.  The  same  observation  holds  good 
for  divers  forms  of  ear  affections.  Measles  is  not  infrequently  asso- 
ciated with  typhoid,  erysipelas,  varicella,  scarlatina,  and  acute  pemphi- 
gus. The  latter  eruption  may  become  gangrenous  and  prove  fatal. 
The  tendency  to  gangrene  of  apparently  mild  lesions  of  the  mucous 
membranes  and  skin  should  always  be  borne  in  mind,  as  it  is  not  at 


362  DISEASES   OF    CHILDREN 

all  rare  to  find  general  sepsis  supervening  just  such  lesions.  Measles 
acts  as  a  great  predisposing  cause  to  pertussis,  which  latter  may  prove 
very  serious,  owing  to  early  supervention  of  bronchopneumonia.  Sudden 
heart  paralysis  is  rare. 

Among  the  sequelfe  the  following  affections  deserve  special  empha- 
sis: otitis,  chronic  conjunctivitis,  keratitis,  deafness,  deafmutism,  os- 
teomyelitis, purulent  pleurisy  or  pericarditis,  nephritis,  chronic  bron- 
chopneumonia, psychoses,  meningitides  and  other  nerve  affections. 

Measles  manifests  also  a  great  disposition  towards  pulmonary  tubercu- 
losis (from  5  to  15  per  cent  of  cases  in  some  epidemics).  As  distin- 
guished from  scarlatina  the  blood  in  measles  shows  a  subnormal  num- 
ber of  leucocytes  or  a  leucopenia. 

Fortunately,  most  of  the  aforementioned  complications  and  sequelae 
are  rare.  Ordinarily,  measles  runs  a  benign  course.  Still,  measles 
should  always  be  looked  upon  as  a  very  serious  disease,  especially  if 
it  attacks  very  young  and  delicate  children  and  those  with  a  tainted 
hereditary  disposition.  Indeed,  in  such  children,  especially  if  housed 
in  asylums  or  hospitals,  the  mortality  may  vary  from  20  to  40  per 
cent. 

Treatment. — The  custom  still  prevailing  with  some  ignorant  people 
to  congregate  the  children  free  from  measles  with  those  affected  by  it, 
so  that  ''they  should  all  have  it  at  once"  is  condemnable.  Isolation 
of  the  patient  should  be  insisted  upon,  and  all  other  precautions  avail- 
able strictly  adhered  to.     (See  p.  69.) 

The  use  of  convalescent  serum  as  a  preventive  and  curative  of 
measles  has  lately  engaged  the  attention  of  pediatrists.  The  results 
are  still  sub  judice.  The  usual  measures  in  the  treatment  of  measles 
consist  principally  of  active  diaphoresis  by  hot  drinks,  hot  baths,  and 
diaphoretics  (decoction  of  crocus  one  dram  to  i/^  pint),  and  minute 
doses  of  an  opiate  and  expectorants  to  relieve  and  loosen  the  cough. 
Attention  to  complications  is  all  important,  whether  grave  or  mild.  A 
light  diet  should  be  enforced  as  long  as  the  temperature  is  above 
normal.  The  fear  of  free  ventilation  of  the  sick-room  is  unfounded. 
On  the  contrary,  a  liberal  supply  of  fresh  air  (68°  to  70°  F.)  should 
be  allowed  as  a  therapeutic  measure.  Where  photophobia  exists,  the 
room  should  be  darkened  by  shades. 

The  mouth  and  eyes  should  be  kept  clean  with  warm  boracic  acid 
solutions,  and  the  nasopharynx  by  instillations  of  a  few  drops  of  al- 
bolene.  The  temperature  and  nerve  irritability  should  be  reduced  by 
small  doses  of  phenacetin  (1/2  grain  for  every  year  of  the  child's  age) 
as  well  as  by  warm  baths  or  packs  (90°  F.). 

Other  symptoms  should  be  treated  according  to  indications. 


SPECIFIC    COMMUNICABLE   DISEASES 


363 


IJ     Liq.  Ammoiiii  Anisat.  3  ss  2.0 

Potassii  Citiatis 

8yr.  Ipecaeuanhae  afi  3  i  4.0 

Syr.  Picis  3  iv  15.0 

Aq.  Aiiisi  q.  s.  f  5  ii         60.0 

M. 
S. — One  teasiioonful  every  three  hours,  for  a 
child  four  years  old  (useful  diuretic,  diaphoretic 
and  expectorant).     A  small  dose  of  codeine  or 
heroin  may  be  added,  if  the   cough   interferes 
vvitli  the  child's  rest. 

For  differential  diagnosis  see  p.  398. 

Rubella 

(RoTHELN,  German  Measles,  Epidemic  Roseola) 

On  superficial  examination  rotheln  closely  resembles  measles,  but 
on  careful  ol)servation  it  is  found  to  differ  from  it  in  so  many  respects 
as  to  justify  its  classification  into  a  distinct  disease.  It  is  highly 
communicable  and  often  occurs  in  epidemics.    One  attack  confers  but 


DAY         1      2     3     4-56     7     8     9    10    11    12    13  14   15 

TIM£           MCMENCMCHEMEMEMEMtMeMCMtMtMtult 

Q 

103 

102 

-.J     4           _____ 

:  _     I   3_, 

oil 

.        .           i  \A 

\    L       Vi 

r    f    t      T 

o        -             I     t      1         4: 

100                          ttik     It 

'°°       .  ■       7           r                      __..... 

_n     1  —  t; - 

_     J 

J             :i: — 

i                   _     t., 

0   1              _  :_.i.t- - 

Fig.  87. — Fever  curve  of  German  measles. 

little  immunity  against  another,  and  not  at  all  against  genuine  measles. 
The  incubation  period  lasts  from  ten  to  twenty-one  days,  and  is  gen- 
erally free  from  any  manifestations.  There  are  none  or  very  slight 
prodromata  of  from  twenty -four  to  forty-eight  hours'  duration,  con- 
sisting of  languor,  anorexia,  and  slight  catarrhal  symptoms,  such  as 
mild  injection  of  the  conjunctiva,  short  cough  and  slight  rhinitis.  The 
eruption  usually  appears  suddenly,  first  on  the  face,  and  within  from 
twelve  to  twenty-four  hours  over  the  entire  body.     Often  it  has  dis- 


364  DISEASES    OF    CHILDREN 

appeared  from  the  face  by  the  time  the  extremities  are  involved.  The 
rash  appears  in  tivo  forms.  One  resembles  that  of  measles — pale,  red 
papules,  up  to  the  size  of  a  lentil,  usually  discrete,  rarely  confluent,  and 
momentarily  disappearing  on  pressure.  The  other  form  is  finely  punc- 
tate, and  coalesces  into  diffuse  rose-red  patches — resembling  the  rash 
of  scarlatina.  The  eruptive  stage  lasts  from  three  to  four  days,  and 
is  usually  free  from  severe  general  symptoms.  It  is  occasionally  fol- 
lowed by  slight  desquamation  of  the  upper  part  of  the  thorax  and 
thighs.  During  the  height  of  the  exanthema,  there  may  be  a  rise  of 
temperature,  of  two  or  three  degrees,  but  it  is  only  of  short  duration. 
As  in  measles,  the  mucous  membrane  of  the  throat  is  the  seat  of  dif- 
fuse or  dotted  redness  or  yellowish  miliary  vesicles;  the  buccal  mu- 
cous membrane,  however,  shows  no  Koplik  spots.  Most  patients  com- 
plain of  sore  throat  during  the  acme  of  the  disease,  but  not  nearly  as 
much  as  in  scarlatina.  The  superficial  glands,  particularly  the  suboc- 
cipitals and  those  in  the  region  of  the  angle  of  the  jaw,  the  submax- 
illary, and  less  frequently  those  of  the  axilla,  groin,  etc.,  are  enlarged 
and  tender.  In  severe  cases  there  is  usually  also  moderate  enlargement 
of  the  spleen. 

The  differential  diagnosis  between  rubella  and  rubeola  will  be  outlined 
on  page  398.  Attention  will  here  be  directed,  however,  to  the  frequent, 
nay,  almost  constant,  occurrence  of  free  perspiration  in  rotheln,  a 
symptqm,  almost  never  met  with  in  genuine  measles.  Where  the  rash 
is  scarlatiniform,  it  may  in  the  beginning  be  confounded  with  scarlet 
fever,  but  in  the  latter  affection  there  are  marked  initial  symptoms 
(vomiting!),  high  fever  and  pulse,  and  more  severe  throat  manifesta- 
tions. 

Numerous  so-called  heat  and  stomach  rashes  greatly  resemble  Ger- 
man measles,  and  it  is  not  always  easy  to  tell  them  apart,  particularly 
in  the  absence  of  an  epidemic  of  rotheln.  Under  the  circumstances 
it  is  safer  to  reserve  the  diagnosis  for  about  twenty-four  hours,  and 
watch  the  results  of  a  ''cooling  lotion"  and  a  laxative. 

For  its  differentiation  from  Dukes'  disease,  see  p.  398. 

Rubella  is  considered  the  mildest  of  all  acute  exanthematous  in- 
fectious diseases,  and,  as  a  rule,  terminates  favorably  within  one  week 
from  the  onset  of  the  symptoms.  But  in  view  of  the  occasional  occur- 
rence of  serious  complications  (severe  angina,  bronchopneumonia,  sup- 
purative adenitis,  and  even  meningitis),  it  should  always  receive  proper 
attention,  especially  in  the  way  of  rest  in  bed,  light  diet,  cleansing 
of  the  nasopharynx,  and  good  hygiene.  (See  also  Treatment  of  mea- 
sles p.  362.) 


SPECIFIC    COMMUNICABLE   DISEASES  365 

Diphtheria 

Diphtheria  is  caused  by  a  bacillus  discovered  by  Klebs  and  Loffler 
in  1883.  The  bacillus  is  found  in  the  secretions  and  excretions  of  the 
structures  involved,  and  is  transmitted  usually  through  direct  personal 
communication  (kissing,  sputum,  etc.),  but  probably  also  through  the 
agency  of  dishes,  clothing,  milk,  etc.,  and  through  a  third  person,  the 
so-called  diphtheria  carrier.  The  bacillus  is  very  tenacious  to  life. 
It  is  said  to  remain  in  the  throat  of  convalescents  for  several  months 
or  longer,  and  rooms  previously  occupied  by  diphtheria  patients  and 
left  vacant  for  weeks  frequently  harbor  infective  diphtheria  bacilli, 
having  resisted  disinfection  and  prolonged  ventilation. 

The  diphtheria  bacilli  have  a  predilection  for  the  lining  of  the  naso- 
pharynx and  larynx,  especially  of  children  from  two  to  eight  years 
of  age.  It  is  less  common  in  infants  under  a  year  and  very  exceptional 
in  the  newborn.*  Far  more  seldom  they  attack  other  parts  of  the  body, 
e.  g.,  intestines,  the  eyes,  the  mouth,  and  the  vulva.  After  imbedding 
themselves  into  the  primarily  affected  structures,  the  bacilli  multi- 
ply and  secrete  their  toxins  (albuminoses  and  organic  acids),  which 
enter  the  tissues  and  lymphatics  and  thence  produce  general  infection. 
The  diphtheria  bacillus  is  often  associated  with  strepto-  and  staphylo- 
cocci and  other  bacteria. 

Morbid  Anatomy. — Diphtheria  is  characteristic  for  its  formation  of 
a  fibrinous  exudation  produced  by  the  entrance  of  the  Klebs-Loflfler 's 
bacillus  and  other  microorganisms  into  the  superficial  tissue  layers. 
It  is  primarily  a  superficial  destructive  process  which  always  ends  in 
ulceration  by  separation  of  the  tissues  in  the  form  of  a  true  membrane. 
It  differs  from  a  croupous  process  only  in  the  degree  of  severity  of  the 
inflammation.  Gangrenous  processes  are  sometimes  associated  with 
diphtheria,  extensive  putrid  decompositions  developing  beneath  the 
diphtheritic  infiltration  or  upon  the  base  of  the  diphtheritic  ulcer.  In 
healing,  the  entire  necrotic  process  must  first  slough  off,  and  the  epi- 
thelium be  replaced  by  scar  tissue. 

In  all  cases  the  neighboring  lymphatic  glands  are  swollen,  hyper- 
emie,  intensely  edematous  and  sometimes  phlegmonous;  and  in  severe 


•Becker  states  that  at  the  Jena  maternity  there  were  five  cases  of  nasal  diphtheria  in  new- 
born infants  in  1918  and  four  m  1919.  He  warns  that  bacteriologic  examination  is  indispensable 
for  every  case  of  coryza  in  a  young  infant  and  above  all  when  the  discharge  from  the  nose 
.shows  traces  of  blood.  In  one  case  the  nasal  diphtheria  entailed  general  sepsis  with  mixed  in- 
fection and  necrosis  of  the  arm.  The  snoring  breathing  is  the  first  symptom  to  attract  attention, 
and  then  the  thin,  slightly  purulent  discharge  running  from  one  or  both  nostrils.  It  is  often 
reddisli  or  brownish,  and  erodes  the  upper  lip.  The  membranes  are  generally  far  back  in  the 
nose,  but  can  be  easily  removed.  Becker  ascribes  the  infection  to  carrier  visitors  as  the  most 
probable  source.  On  this  account  it  is  now  the  rule  not  to  give  the  child  to  its  mother  to 
nurse  during  "visiting  hours,"  and  no  outsider  is  allowed  in  the  infants'  ward.  In  a  recent 
compilation  of  thirty -eight  cases  the  mortality  was  31.6  per  cent,  mostly  from  complications. 
In  another  case  the  diphtheria  settled  in  the  cord. 


366  DISEASES   OF    CHILDREN 

cases  there  is  usually  an  extensiou  of  the  diphtheritic  process  from  the 
pharynx  to  the  nose,  larynx,  trachea  and  l)ronclii.  Owino'  to  its  thick 
and  dense  epithelial  covering  the  eso])hag'us  is  very  seldom  involved. 
If  the  lungs  become  affected,  the  lesions  usually  consist  of  small  lo- 
bular pneumonic  foci,  especially  in  the  posterior  lower  portion  of  the 
lungs.  Degenerative  changes  in  the  heart,  spleen,  liver,  kidneys,  in- 
testines and  cerebrospinal  system  are  not  uncommon  evidences  of  the 
diphtheria  toxin.     The  blood  shows  no  definite  changes. 

Symptomatology. — The  incubation  period  varies  from  two  to  ten  days. 
As  a  rule,  the  onset  is  sudden  with  vomiting,  headache,  chills,  fever,  sore 
throat,  and  difficulty  in  swallowing.  Not  rarely  however  it  is  preceded  by 
indefinite  signs  of  ill  health  of  *a  few  days'  duration,  consisting  of  ano- 
rexia, lassitude,  slight  fever,  irritation  of  the  respiratory  tract,  etc.  In 
such  cases  the  active  stage  of  tlie  disease  may  insidiously  follow  upon  the 
prodromic  stage  Avithout  any  pronounced  variation  in  the  clinical  mani- 
festations, the  throat  symptoms  often  remaining  latent  until  discovered 
by  a  routine  examination  or  unmasked  by  grave  correlative  symptoms. 
This  is  especially  apt  to  occur  in  infants.  The  importance  of  a  routine 
examination  of  the  throat  of  children  in  all  kinds  of  complaints,  there- 
fore, is  obvious. 

The  initial  symptoms  of  the  disease  are  not  very  characteristic, 
especially  if  the  attack  is  mild.  The  uvula  and  tonsils  are  inflamed 
and  somewhat  enlarged.  Careful  inspection  of  the  throat  usually  re- 
veals upon  the  inner  tonsillar  or  faucial  surfaces  a  small,  uneven, 
grayish-white,  slightly  elevated  patch,  or  a  tew  gray  streaks  or  hem- 
orrhagic specks.  Within  a  few  hours  the  deposit  is  found  to  have 
spread  over  both  tonsils  or  also  to  the  palatine  arches  and  the  posterior 
pharyngeal  wall,  giving  the  appearance  of  a  greenish-white,  sharply 
defined,  firmly  adherent  membrane,  which,  if  forcibly  detached,  leaves 
a  raw,  bleeding  surface,  and  reforms  very  soon  after.  As  the  deposit 
assumes  greater  dimensions,  the  cervical  and  submaxillary  glands, 
which  at  first  are  but  slightly  involved,  become  large  and  hard,  assume 
the  shape  of  large  walnuts,  and  are  very  painful  to  the  touch.  De- 
glutition is  difficult  but  not  very  painful — due  to  partial  degeneration 
of  the  pharyngeal  muscles  and  their  nerves.  The  aforementioned  con- 
stitutional symptoms  continue. 

The  symptomatology  thus  far  represents  the  first  stage  of  a  mod- 
erately severe  attack  of  pharyngeal  diphtheria.  From  now  on  three 
eventualities  are  possible:  (1)  The  clinical  picture  may  remain  sta- 
tionary; (2)  the  disease  may  spread  to  the  nose  from  the  pharynx;  (3) 
the  diphtheritic  process  may  extend  downward  to  the  larynx. 


PLATE  VII 


ToxsiLLAK  Diphtheria 

(Courtesy  of  Dr.  John  Zahorsky.) 


SPECIFIC    COMMTNICABLE    DISEASES  367 

Since  tlio  introduction  of  antitoxin  treatment  of  diphtheria  the  numl)er 
of  eases  falling  into  the  first  category  has  enormously  increased.  With 
early  treatment  the  disease  is  rapidly  arrested,  the  membranes  are  cast 
off  spontaneously,  and  the  patient  makes  an  uneventful  recovery  with- 
in from  four  to  eight  days.  Less  frequently  the  second  or  third  pos- 
sibility occurs.  Either  as  a  result  of  extreme  virulence  of  the  in- 
fection or  of  negligence  or  improper  treatment,  the  nose  or  larynx 
or  both  becomes  invaded.  In  nasal  diphtheria  {rhinitis  fihrinosa  et 
memhranacea) ,  in  addition  to  the  previously  mentioned  symptoms,  nasal 
breathing  is  obstructed  greatly.  The  child  keeps  the  mouth  widely 
open,  snores,  is  very  restless,  speaks  through  the  nose,  is  almost 
unable  to  swallow,  has  fetor  ex  ore,  and  coryza  with  seropurulent  or 
hemorrhagic  discharge.  In  laryngeal  involvement  (diphtheritic  croup), 
symptoms  of  laryngeal  stenosis  predominate.  The  child's  voice  becomes 
husky,  then  hoarse,  aphonic,  and  its  breathing  noisy,  rough  and  wheez- 
ing, and  as  the  disease  advances,  it  is  attacked  by  a  barking,  croupy 
cough,  dyspnea,  retraction  of  the  lower  portion  of  the  sternum  and  the 
ribs  with  each  inspiration,  and  cyanosis.  The  dyspnea  often  occurs  in 
paroxysms,  which  greatly  resemble  those  of  spasmodic  croup  (q.v.), 
and  grow  worse  from  time  to  time.  Unless  the  air  passages  are  promptly 
freed  from  the  obstruction  by  intubation  (q.v.)  or  tracheotomy  (q.v.), 
the  patient  passes  into  a  state  of  stupor  and  finally  succumbs  to  the 
effects  of  increase  of  carbonic  acid  and  deficiency  of  oxygen  in  the  lungs. 

Both  laryngeal  and  nasal  diphtheria  may  develop  primarily,  and 
later  become  associated  with  pharyngeal  diphtheria. 

The  course  of  the  disease  varies  greatly  with  the  location  of  the  lesion, 
severity  of  the  attack,  and  the  period  at  which  treatment  is  begun. 
Pharyngeal  diphtheria  usually  pursues  the  most  favorable  course.  Mild 
cases,  as  mentioned,  may  end  in  complete  recovery  in  from  four  to  eight 
days.  In  severer  cases,  the  symptoms  may  increase  in  intensity  up  to 
the  fifth  or  sixth  day,  and  then  begin  to  abate,  and  after  a  rapid  or 
protracted  course  finally  subside.  The  same  holds  true  of  nasal  or  laryn- 
geal diphtheria,  provided  treatment  is  instituted  early  and  no  complica- 
tions supervene.  Unfortunately  in  the  latter  form  of  the  disease  com- 
plications are  of  quite  frequent  occurrence.  Exhausted  from  the  pros- 
trating effects  of  the  paroxysmal  attacks  of  laryngeal  stenosis,  the  child 
is  unable  to  withstand  the  onslaught  of  the  diphtheritic  poison  (some- 
times also  mixed  diphtheritic  and  streptococcic  infections).  The  de- 
posit, originally  limited  to  the  upper  portions  of  the  larynx,  rapidly 
extends  downward,  involving  the  trachea  and  bronchi — leading  to  croup- 
ous bronchitis  and  pneumonia,  and,  as  a  rule,  to  a  fatal  issue — and  up- 
ward, exerting  its  destructive  action  upon  the  pharyngeal,  oral  and  nasal 


368  DISEASES   OF    CHILDREN 

structures,  often  resulting  in  perforation  of  the  palate,  gangrenous 
sloughing  of  the  uvula,  etc.  These  cases  of  so-called  diphtheria  (jravis- 
sima  s.  maligim  sometimes  develop  very  slowly  and  insidiously  {diph- 
theria larvata)  with  symptoms  of  slight  indisposition,  slight  rise  of  tem- 
perature, bronchial  or  gastrointestinal  catarrh,  and  after  a  period  of 
from  a  week  to  ten  days  are  abruptly  announced  by  true  croup  and  the 
accompanying  grave  manifestations.  Occasionally  this  form  of  the  dis- 
ease pursues  a  septic  course  right  from  the  start,  irrespective  of  the 
location  and  extent  of  the  deposit.  The  virulent  process  is  supposed 
to  be  due  not  only  to  the  diphtheria  toxin,  but  to  the  immediate  entrance 
of  the  bacillus  itself  into  the  circulation.  It  is  characterized  by  vomiting, 
prostration,  puffiness  and  earthy  pallor  of  the  face ;  small,  often  irregu- 
lar pulse ;  epistaxis ;  bleeding  from  the  mouth,  pharynx  or  into  the  skin. 
The  urine  is  scanty,  loaded  with  albumin;  the  temperature  may  be 
slightly  raised  or  below  normal.  Within  from  three  to  five  days  the 
child  dies,  in  a  state  of  low  muttering  delirium,  from  gradual  exhaustion, 
or  earlier  from  cardiac  paralysis.  On  postmorten  examination,  in  addi- 
tion to  the  diphtheritic  lesions  pathognomonic  of  all  forms  of  the  disease, 
the  spleen  is  found  enlarged,  the  kidneys,  liver,  and  heart  in  a  state  of 
cloudy  swelling — a  group  of  pathologic  findings  ordinarily  met  with  in 
severe  infectious  diseases — and,  varying  with  the  intensity  and  number 
of  complications,  divers  lesions  in  other  organs  of  the  body  (e.g.,  lungs, 
brain  and  alimentary  canal). 

There  is  nothing  definite  about  the  number  and  severity  of  the  com- 
plications in  any  given  case.  As  already  stated,  mild  cases  may  become 
severe  and  exhibit  all  sorts  of  complications  and  sequel©  and  vice  versa, 
cases  with  severe  onset  may  under  proper  treatment  remain  free  from 
either  and  end  favorably  in  a  comparatively  short  space  of  time.  Kid- 
ney, heart,  lungs  and  nerve  diseases  form  the  most  frequent  complica- 
tions and  sequelae  and  in  the  majority  of  instances  are  the  result  of  mixed 
infection.  Transient  albuminuria  is  often  observed  even  in  mild  cases. 
It  usually  begins  on  the  third  or  fourth  day  of  the  disease,  sometimes 
earlier  or  later,  and  disappears  with  abatement  of  the  other  diphtheritic 
symptoms.  Occasionally  we  find  true  nephritis  diphtheritica,  with  large 
quantities  of  albumin  and  casts  and  more  rarely  also  blood.  The  neph- 
ritis may  also  set  in  as  a  late  sequel,  during  apparent  convalescence, 
and  remain  more  or  less  permanent.  As  a  rule,  however,  the  nephritis 
is  of  short  duration,  and  rarely  gives  rise  to  local  or  general  dropsy. 
By  far  more  serious  is  the  accompanying  heart  affection — so-called 
"heart  paralysis"  from  involvement  of  the  pneumogastric  nerve.  It  is 
often  manifested  by  sudden  heart  failure,  and  may  set  in  either  during 
the  acme  of  the  disease  or  any  other  time  between  then  and  as  late  as 


SPECIFIC    COMMUNICABLE   DISEASES  369 

from  four  to  six  weeks  after ;  sometimes  while  the  patient  seems  in  very 
good  health.  It  is  apt  to  arise  on  the  slightest  exertion.  The  heart  paral- 
ysis is  not  invariably  sudden  and  fatal,  however.  Quite  often  it  is  pre- 
ceded by  heart  weakness  with  symptoms  of  dilatation — interstitial  myo- 
cardial degeneration — such  as  extreme  pallor,  feeble,  rapid  and  irregu- 
lar pulse,  attacks  of  syncope,  albuminuria,  exhausting  diarrhea,  some- 
times apathy,  somnolence,  sopor  and  death;  or,  less  frequently,  very 
slow  convalescence,  and  gradual  recovery,  usually  with  remaining  heart 
disease.  Occasionally  diphtheria  is  complicated  by  pericarditis  or  endo- 
carditis. Bronchitis  and  pneumonia  are  especially  prone  to  occur  in 
laryngeal  diphtheria,  as  a  result  of  direct  extension  of  the  diphtheritic 
process  to  the  trachea,  bronchi,  etc.  (in  intubated  cases  through  the 
entrance  of  foreign  bodies,  particles  of  food,  etc.,  into  the  air  passages — 
"aspiration  pneumonia")  but  also  in  other  forms  of  the  disease.  The  oc- 
currence of  pneumonia  greatly  mars  the  prognosis. 

The  most  frequent  sequel — occasionally  also  complication — of  diph- 
theria is  multiple  neuritis,  "diphtheritic  paralysis,"  It  is  due  to 
an  intense  degeneration  of  the  peripheral  nerves  up  to  their  roots.  It 
follows  in  about  one-tenth  of  all  cases,  probably  mild  and  severe  alike. 
It  generally  develops  about  the  third  or  fourth  week  after  the  onset 
of  diphtheria,  sometimes  earlier  or  later,  and  affects  the  muscles  of 
the  soft  palate  by  preference,  causing  a  nasal  tone  of  voice,  and  re- 
gurgitation of  fluids  through  the  nose.  In  combined  esophageal  and 
laryngeal  paralysis  there  is  also  great  difficulty  in  deglutition,  not 
rarely  giving  rise  to  "aspiration  pneumonia,"  as  a  result  of  entrance 
of  part  of  the  food  into  the  air  passages.  These  disturbances  usually 
disappear  spontaneously  or  on  suitable  treatment,  within  from  four 
to  six  weeks.  The  paralysis  may  extend  to  the  eye  muscles  and  cause 
strabismus,  oculomotor  paralysis,  disturbance  of  accommodation  and 
even  total  ophthalmoplegia.  Less  frequently  the  muscles  of  the  trunk 
and  extremities  are  implicated.  (See  Fig.  196.)  The  symptoms  resulting 
are  more  or  less  identical  with  those  observed  in  cases  of  multiple  neur- 
itis from  other  causes,  and  vary  in  intensity  from  simple  motor  weakness 
and  ataxic  gait  to  hemiplegia.  In  severe  cases  the  tendon  reflexes  and 
faradic  irritability  are  entirely  lost,  and  the  muscles  undergo  atrophy. 
Nevertheless,  recovery  is  the  rule  in  the  majority  of  cases,  except  when 
complicated  by  paralysis  of  the  respiratory  muscles  (diaphragm)  and 
the  aforementioned  baleful  sudden  heart  failure.  As  regards  the  hemi- 
plegia, it  is  still  uncertain,  whether  it  is  a  genuine  diphtheritic  paral- 
ysis or  caused  by  underlying  alteration  in  the  brain,  such  as  cerebral 
hemorrhage,  or  cardiac  thrombosis  with  embolism  of  the  arteria  fossae 
Sylvii,  since  the  hemiplegia  not  rarely  begins  with  convulsions,  loss 


370 


DISEASES    OF    CHILDREN 


of  consciousness,  and  is  often  associated  with  aphasia  and  facial  paral- 
ysis. If  the  patient  survives  the  attack,  the  hemiplegic  symptoms  usu- 
ally subside  within  a  few  weeks,  but  weakness  and  contractures  of  the 
extremities  may  remain  permanent. 

Less  common  complications  and  sequelae  are  arthritides,  otitis,  pleu- 
ritis,  peritonitis,  suppurative  adenitis,  diphtheritic  affections  of  the 
stomach,  diphtheritic  ophthalmia,  various  rashes,  etc. 

From  the  foregoing  discussion  it  can  readily  be  appreciated  that 
a  positive  prognosis  is  almost  impossible.  It  shovild  always  be  guarded, 
no  matter  how  mild  the  case.    The  gravity  of  the  epidemic,  the  sever- 


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With  Each  Day's  Delay  in  Giving  Anti- 
toxin, See  How  the  Danger  Increases  I 

Chart  I 


ity  of  the  attack,  the  strength  and  age  of  the  patient,  the  quality  of 
the  heart,  the  period  at  which  antitoxin  has  been  administered — all 
have  an  important  bearing  upon  the  outcome  of  the  case.  However, 
no  case  should  be  despaired  of,  no  matter  how  grave.  Antitoxin  treat- 
ment often  performs  miracles,  even  in  apparently  hopeless  cases. 

Treatment. — With  the  advent  of  the  serum  treatment,  diphtheria 
has  ceased  to  be  the  dread  of  the  community.  The  mortality  of  diph- 
theria which  previously  ranged  between  50  and  75  per  cent,  has  now 
dropped  to  about  5  per  cent  in  pharyngeal  and  to  20  per  cent  in  laryn- 
geal diphtheria — the  earlier  the  serum  treatment  is  begun  with  the 


SPECIFIC    COMMUNICABLE   DISEASES  371 

lower  the  mortality.  Indeed,  by  administering  diphtheria  antitoxin 
at  the  very  inception  of  the  disease  we  are  often  enabled  to  limit  the 
latter  to  its  local  manifestations — almost  free  from  constitutional  sj-mp- 
toms.  Furthermore,  those  coming  in  close  contact  with  the  diphtheria 
patient  may  by  means  of  from  500  to  1,000  units  of  antitoxin  be  im- 
munized against  this  affection  for  a  period  of  from  four  to  six  weeks. 

In  a  great  many  instances,  especially  in  children's  hospitals  and  asy- 
lums where  large  numbers  of  children  are  congregated,  immunization 
may  in  many  cases  be  dispensed  with  by  employing  Schick's  toxin  skin 
reaction  (see  p.  74),  since  it  enables  us  to  determine  the  susceptibility 
to  or  immunity  against  diphtheria.  Moreover,  as  already  emphasized  on 
pp.  75,  76  permanent  immunity  may  be  effected  by  means  of  diphthe- 
ria toxin-antitoxin. 

Immunization  and  isolation  of  the  patient  are  the  most  potent  prophy- 
lactic measures  of  diphtheria.  As  the  nasopharynx  forms  the  prin- 
cipal nidus  for  the  development  and  spread  of  the  diphtheria  bacilli 
and  their  toxins,  cleansing  of  the  nasopharynx  by  means  of  mild 
antiseptics  (instillation  of  Dobell's  solution  three  or  more  times  a 
day)  will  often  aid  in  the  prevention  of  infection.  This  prophylactic 
measure  should  be  employed  in  conjunction  with  immunization  by 
antitoxin,  or  without  the  latter,  wherever  there  are  contraindications 
to  its  use  {e.g.,  status  lymphaticus,  hemophilia)  or  objections  on  the 
part  of  the  family.  Heart  disturbances  being  the  most  dangerous  com- 
plication of  diphtheria,  the  heart  should  receive  very  careful  attention^ 
even  in  the  mildest  form  of  the  affection.  It  should  be  examined  daily, 
especially  as  regards  acute  dilatation  of  the  heart.  The  patient  should 
be  kept  under  observation  for  at  least  three  weeks  after  abatement  of 
the  acute  course  of  the  disease,  and  in  the  event  of  any  untoward  symp- 
toms arising,  immediately  be  put  to  bed  and  treated  in  accordance  with 
the  directions  presently  to  be  outlined.  Even  with  an  apparently  nor- 
mal heart  it  is  imperative  to  keep  the  child  perfectly  at  rest  in  bed 
for  at  least  ten  days  after  disappearance  of  the  local  symptoms.  As  to 
the  prevention  of  "aspiration  pneumonia,"  the  reader  is  referred  to  the 
chapter  on  ''Intubation." 

The  active  treatment  of  diphtheria  can  be  summarized  in  a  few  words : 
counteract  the  diphtheria  toxin ;  arrest  the  local  lesion ;  and  increase 
the  power  of  resistance  of  the  patient.  When  called  upon  to  see  a  case 
of  sore  throat  or  laryngitis  that  is  strongly  suspicious  of  being  diph- 
theritic in  nature,  we  should  immediately  administer  diphtheria  anti- 
toxin and  lose  no  time  in  waiting  for  the  results  of  a  bacteriologic  exami- 
nation. The  serum  should  be  administered  by  deep  hypodermic  in- 
jections, a  syringe  somewhat  larger  than  the  ordinary  hypodermic  syr- 


372  DISEASES   OF    CHILDREN 

inge  being  preferably  employed  for  this  purpose.  The  lateral  surface  of 
the  abdomen  or  thorax  or  the  outer  surface  of  the  thigh,  where  there  is 
an  abundance  of  subcutaneous  cellular  tissue,  is  generally  chosen  for 
the  injections.  Previous  to  the  administration  of  the  antitoxin  the 
skin  should  be  carefully  washed  with  alcohol  or  some  disinfecting  solu- 
tion and  the  syringe  carefully  sterilized.  Nowadays  the  serum  is  ob- 
tainable in  clean  hermetically  sealed  syringes,  rendering  their  steriliza- 
tion unnecessary.  Children  under  two  years  of  age  should  receive  from 
3  to  5,000  units  of  antitoxin,  and  those  over  this  age  from  5  to  10,000 
units.  Equal  or  smaller  doses  may  be  given  after  about  eight  hours,  if 
no  improvement  is  observed.  The  antitoxin  injection  is  somtimes  fol- 
lowed (within  from  two  days  to  two  weeks)  by  an  erythema  or  urticaria- 
like eruption  which  usually  disappears  without  any  special  treatment. 
In  malignant  cases  or  in  those  seen  late,  double  doses  should  be  adminis- 
tered at  once  and,  if  necessary,  repeated,  or  the  antitoxin  may  be  ad- 
ministered intravenously  (after  warming  the  antitoxin  in  its  container 
in  hot  water).  The  effect  of  the  serum  is  very  beneficial,  nay,  sometimes 
Vnagical.  After  a  temporary  rise,  the  fever  often  falls  by  crisis,  the 
pulse  improves,  the  membranes  loosen  and  disappear,  and  the  whole  as- 
pect of  the  case  sometimes  changes  completely  for  the  better,  within 
from  eighteen  to  twenty-four  hours.  However,  notwithstanding  all  that 
was  said  in  favor  of  the  antidiphtheritic  serum,  it  is  not  always  advisa- 
ble to  depend  upon  the  serum  alone. 

As  diphtheria  is  originally  a  local  affection  and  the  secretion  and  ab- 
sorption of  the  metabolic  products  (toxins)  occur  from  the  local  lesion, 
the  urgency  of  the  immediate  destruction  of  the  bacilli  at  their  point 
of  entrance  is  self-evident.  This  is  best  accomplished  by  the  different 
germicides  and  solvents,  such  as  peroxide  of  hydrogen,  strong  solu- 
tions of  carbolic  or  salicylic  acid,  20  per  cent  to  50  per  cent  solutions 
of  resorcin  in  alcohol,  tincture  iodine,  argyrol  or  solargentum  (20  per 
cent),  or  the  carbol-camphor  solution  referred  to  on  p.  295.  Milder  so- 
lutions of  the  same  preparations  should  be  used  also  for  cleansing  the 
nose,  even  in  the  absence  of  any  lesion  there.  The  local  treatment 
should  be  repeated  every  two  to  four  hours  and  continued  until  total 
disappearance  of  the  acute  symptoms  of  diphtheria. 


Glyeerit.  Papain. 

3iv 

Acid  Carbolici 

aa 

15.0 

Pulv.  Camphorae 

gr.  X 

0.65 

Alcoholis 

3ii 

8.0 

Glycerini 

q- 

s.  f  5  ii 

60.0 

This  is  applied  to  the  throat  by  means  of  a  cotton  swab  every  two 
hours — changing  the  swab  each  time — diminishing  the  frequency  of 


SPECIFIC    COMMUNICABLE   DISEASES  373 

applications  with  the  abatement  of  the  severity  of  the  symptoms. 
Flushing  of  the  throat  with  a  warm  solution  of  boric  acid  or  bicarbo- 
nate of  soda  (2  drams  to  1  quart  of  water)  by  means  of  an  irrigator 
is  very  beneficial. 

The  third  indication,  to  increase  the  power  of  resistance  of  the  pa- 
tient, should  be  met  by  an  abundance  of  nutritious,  easily  digestible 
food,  stimulants  and  hematinics.  Feeding  of  the  little  patient  is  as 
difficult  as  it  is  important.  As  a  rule,  total  anorexia  prevails  and  it 
requires  a  great  deal  of  patience  and  tact  to  induce  the  child  to  swal- 
low a  few  mouthfuls  of  milk,  beef  juice,  ice  cream,  fruit  juices,  etc. 
Still,  much  may  be  gained  by  administering  the  nourishment  in  small, 
frequently  repeated  quantities,  and  in  small  children,  if  need  be,  by 
rectal  alimentation  (peptonized  milk).  As  a  food  and  stimulant  good 
wines  and  cognac  are  of  inestimable  value  in  diphtheria,  especially  in 
the  septic  variety.  In  malignant  cases  it  should  be  given  well  diluted 
in  large,  frequently  repeated  doses  (1  to  2  drams  every  two  hours), 
preferably  by  mouth,  and  in  urgent  cases,  cognac  in  smaller  doses 
also  hypodermically.  It  is  advisable  to  employ  mild  stimulation  from 
the  earliest  inception  of  the  disease,  and  to  continue  it  for  weeks  after 
in  order  to  obviate — at  least  to  a  certain  extent — sudden  heart  failure. 
A  useful  combination  which  acts  both  as  stimulant  and  hematinic,  is 
the  following: 

IJ     Strychninae  Sulph.  gr.i^,         0.01 

Liq.  Ferri  et  Ammonii  acetatis  §  ii       60.0 
M. 
S. — One   teaspoonful,    diluted   in    sweetened 

water,  every  six  hours. 

Whenever  the  local  as  well  as  systemic  effect  of  iron  is  desirable, 
the  iron  and  myrrh  mixture  referred  to  on  p.  391  answers  the  purpose 
admirably.  Any  untoward  symptoms  arising  should  be  combated  ac- 
cording to  indications.  In  heart  weakness,  strychnine  and  digitalis 
should  be  pushed  to  full  tolerance. 

In  laryngeal  diphtheria  without  nasopharyngeal  lesions,  the  local 
treatment  outlined  for  the  pharyngeal  involvement  may  be  dispensed 
with.  Occasional  cleansing  of  the  nose  and  throat  with  a  5  to  10  per 
cent  solution  of  argyrol,  silvol,  or  solargentum  or  Dobell's  solution, 
however,  is  useful  as  a  preventive  measure.  It  is  of  advantage  also  to 
have  the  patient  inhale  medicated  vapors,  such  as  the  following: 

IJ     Acid.  Carbolici  3  ss        2.00 

Eucalyptol  3  i        4.00 

.    Tr.  Benzoini  Compound  q.s.  ad  f  5ii      60.00 

M. 
S. — One  teaspoonful  in  a^  pint  of  hot  water,  for  inhalation. 


374  DISEASES    OF    CHILDREN 

With  early  administration  of  aiitidiphtheritic  serum  the  laryngeal 
stenosis  rarely  attains  such  severity  as  to  demand  relief  by  intubation 
(see  p.  376)  or  tracheotomy  (see  p.  381).  Mild  paroxysmal  attacks 
of  dyspnea  often  yield  to  emesis  (I/2  dram  of  wine  of  ipecacuanha, 
or  1/20  grain  of  apomorphine  hydrochlorate),  and  a  small  dose  of 
morphine  (1/50  grain)  and- atropine  (1/500  grain).  But  if  these  rem- 
edies fail,  intubation  or  tracheotomy  should  be  resorted  to.  It  is  always 
preferable  to  intubate  (or  tracheotomize)  early  ratlier  than  late.  When- 
ever the  dyspnea  is  steadily  increasing  in  intensity  and  the  temperature 
rises,  this  life-saving  measure  is  indispensable,  and  procrastination  is 
apt  to  prove  fatal. 

Differential  Diagnosis 

1.  Pharyng-eal  Diphtheria. — (a)  Pseudomembrane. — In  pharyngeal 
diphtheria  the  pseudomem])rane  appears  as  a  small,  uneven,  grayish- 
white,  slightly  elevated  patch  upon  the  inner  or  faucial  surfaces  of  the 
throat.  The  deposit — which  contains  diphtheria  bacilli — augments  by 
quick  spreading,  reaching  within  a  few  hours  the  posterior  wall  of  the 
pharynx,  and,  in  severe  cases,  the  Eustachian  tubes,  nares,  and,  more 
rarely,  the  conjunctiva.  Anteriorly  the  pseudomembrane  attacks  the 
palatal  arch  and  uvula.  It  may  spread  downward  into  the  larynx  or 
alimentary  canal.  The  surrounding  uncovered  areas  are  grayish  in  color, 
due  to  overcrowding  of  leucocytes,  nuclei,  and  mucus  beneath.  The  ton- 
sils, as  a  rule,  are  but  slightly  enlarged.  The  deposit,  if  removed,  leaves 
a  raw,  bleeding  surface  and  reforms  rapidly. 

In  follicular  amygdalitis  the  deposit  begins  as  one  or  more  white  small 
pellicles  upon  the  middle  or  anterior  portion  of  the  tonsil.  The  pellicles, 
at  first  distinctly  isolated,  gradually  coalesce,  forming  elevated  patches. 
They  are  limited  to  the  tonsils,  may  easily  be  removed,  and  reform  slowly. 
The  tonsil,  usually  one,  is  moderately  enlarged,  sometimes  previous  to 
the  appearance  of  the  deposit. 

In  parenchymatous  amygdalitis  the  tonsil  is  greatly  enlarged,  often  dis- 
placing the  uvula.  It  is  bluish  in  color  and  doughy  in  consistency.  The 
deposit,  at  first  white,  soon  becomes  yellowish,  resembling  the  "point" 
of  an  abscess. 

In  necrotic  amygdalitis  or  Vincent's  angina  the  tonsils  are  moderately 
have  a  tendency  to  burst  and  leave  superficial  ulcers.  This  form  of 
amygdalitis  is  at  times  accompanied  by  stomatitis.  Otherwise  it  resem- 
bles follicular  amygdalitis. 

In  necrotic  aniygdalitis  or  Vincent's  angina  the  tonsils  are  moderately 
enlarged  and  the  deposit  lies  deeply  imbedded  within  the  structure  of 
the  mucous  membrane.     The  deposit,  if  removed,  leaves  behind  a  deep 


SPECIFIC    COMMUNICABLE   DISEASES  375 

ulcer — sometimes  gangrenous — surrounded  by  a  distinct  red  zone;  it 
spreads,  as  a  rule,  from  one  tonsil  to  the  other  by  way  of  the  anterior 
pillars  and  palatal  arch,  frequently  attacking  also  the  uvula. 

Vincent's  angina  and  septic  sore  throat  are  best  diagnosed  by  a  culture 
from  the  tonsillar  deposits. 

(b)  Submaxillary  Glands. — The  submaxill9,ry  glands  in  diphtheria 
are  greatly  involved.  They  are  large  and  hard,  assuming  the  shape 
of  a  large  walnut,  and  can  easily  be  seen  protruding  from  the  angle  of 
the  jaw.     They  are  very  painful  to  the  touch. 

In  follicular  and  herpetic  amygdalitis  the  glands  are  moderately  en- 
larged, softer  in  consistence  and  less  painful  to  the  touch  than  m  diph- 
theria. 

In  parenchymatous  amygdalitis  the  glands  are  moderately  enlarged  and 
diffuse,  the  swelling  often  extending  as  high  as  the  ear. 

In  necrotic  amygdalitis  the  glands  differ  but  slightly  from  those  of 
diphtheria  and  cannot  be  relied  upon  as  a  differential  point  of  diagnosis. 

(c)  Early  Constitutional  Symptoms. — Except  the  presence  of  albu- 
min in  diphtheritic  urine,  none  of  the  early  constitutional  symptoms 
are  characteristic  of  diphtheria.  Indeed,  they  are  frequently  less 
pronounced  in  diphtheria  than  in  any  other  throat  affections,  unless 
the  former  is  complicated  by  streptococcic  infection.  The  temperature 
in  diphtheria,  as  a  rule,  is  moderate,  about  101°  to  103°  F.,  and  con- 
tinuous. The  pulse  is  feeble  and  quick  and  soon  gives  signs  of  exhaus- 
tion. The  face,  as  a  rule,  is  pale.  SwalloAving  is  difficult,  but  not 
very  painful,  due  to  partial  degeneration  of  the  muscles  of  deglutition 
and  their  nerve  supply.  Albuminuria  is  invariably  present  from  the 
earliest  beginning  of  the  disease  and  is  of  great  significance  in  the 
differential  diagnosis. 

In  the  various  forms  of  amygdalitis  the  temperature  is  quite  high, 
especially  toward  evening,  often  reaching  105°  F.  The  face  is  flushed. 
Deglutition  is  painful  and  difficult  as  a  direct  result  of  soreness  and 
sensitiveness  of  the  tonsils.    Albuminuria  is  usually  absent. 

The  diagnosis  of  scarlatinal  angina  is  at  best  very  difficult.  It  may 
be  taken  for  granted  that  the  primary  amygdalitis  of  scarlet  fever  is 
scarlatinal  in  nature,  and  that  the  sore  throat  which  sets  in  several  days 
after  is  diphtheritic.  It  should  be  left,  however,  to  the  bacteriologic  test 
to  clear  up  the  diagnosis. 

2.  Laryngeal  Diphtheria.— Laryngeal  diphtheria  can  only  be  mis- 
taken for  nondiphtheritic  membranous  laryngitis  (see  p.  310),  and 
spasmodic  laryngitis.  In  both  of  these  affections,  however,  the  Klebs- 
Loefifler  bacillus  is  absent. 


376  DISEASES   OF    CHILDREN 

Intubation  in  Laryngeal  Diphtheria 

Before  discussing  the  subject  in  question  I  deem  it  opportune  again 
to  recall  the  great  services  rendered  by  the  master  of  intubation,  the 
late  Dr.  Joseph  O'Dwyer,  of  New  York,  who  after  numerous  failures 
and  discouragements  finally  succeeded  in  presenting  to  the  world  a 
priceless  gift  in  the  form  of  an  intubation  set,  which  has  saved  multi- 
tudes of  children  from  gradual,  agonizing  death.  Before  this  mar- 
velous invention  was  fully  accepted  by  the  medical  profession.  Dr. 
O'Dwyer  had  been  frequently  humiliated  by  incompetent  and  possibly 
envious  critics,  rather  than  honored,  remunerated,  and  decorated,  by 
his  state  or  country,  or  perpetuated  in  bronze  or  granite,  as  he  surely 
would  have  been,  had  he  been  as  successfully  engaged  in  the  acts  of  de- 
struction, in  the  art  of  warfare,  instead  of  in  a  deed  of  mercy. 

My  records  of  the  past  five  years,  during  which  time  I  have  had 
the  privilege  of  intubating  sixty-eight  children  suffering  from  laryngeal 
diphtheria,  show  but  one  fatal  issue.  This  favorable  result  was  un- 
doubtedly due  to  the  facts,  first,  that  the  physicians  in  attendance  had 
promptly  administered  ample  doses  of  antitoxin  to  neutralize  the 
diphtheritic  toxin;  and  secondly,  that  the  intubation  was  done  early. 
It  may  be  noted  that  all  these  children  remained  in  their  own  homes, 
often  in  most  undesirable  surroundings,  and  without  skilful  nursing. 
Four  of  them  lived  out  of  town,  requiring  two  or  three  hours'  jour- 
ney to  reach.  To  emphasize  the  absolute  feasibility  and  perfect  safety 
with  which  intubation  can  be  performed  even  under  the  most  trying 
conditions,  we  may  briefly  relate  the  following  case: 

L.  P.,  four  years  old,  the  son  of  Slavish  parents  in  the  poorest  district  of  Perth 
Amboy,  N.  J.,  had  been  ill  for  three  days  before  consulting  Dr.  S.  Finding  in- 
volvement of  the  nasopharynx  and  larynx,  he  immediately  administered  10,000  units 
of  antitoxin  and  prescribed  other  remedies  ordinarily  in  use.  During  the  night  the 
child  got  very  much  worse  and  the  laryngeal  stenosis  had  assumed  alarming  in- 
tensity by  the  time  we  arrived  there.  Owing  to  considerable  tumefaction  and  un- 
usual depth  of  the  larynx,  intubation  was  somewhat  difficult,  but  the  boy  obtained 
prompt  relief  with  introduction  of  the  tube.  After  giving  10,000  units  of  anti- 
toxin and  ordering  absolute  rest,  we  left  the  child,  practically  without  any  specific 
directions^  under  the  care  of  the  mother,  who  was  entirely  helpless  and  unable  to 
understand  our  language.  Five  days  later  we  returned  for  extubation,  and,  to  our 
great  amazement,  we  were  met  at  the  door  by  the  little  patient,  tube  still  in  the 
throat,  but  apparently  perfectly  happy.  Extubation  was  comparatively  easy,  and 
the  boy  required  no  after-treatment  whatever. 

This  case,  among  several  similar  ones,  has  fully  convinced  me  that 
intubation  can  be  performed  without  hesitancy  even  in  the  humblest 
of  homes  without  any  preparations  or  skilful  after-treatment.  This 
optimism  is  not  shared  by  a  goodly  number  of  clinicians,  one  group  of 


SPECIFIC    COMMUNICABLE   DISEASES  377 

whom,  discarding  intubation  entirely  as  a  dangerous  operation  and 
preferring  tracheotomy,  with  the  certain  dangers  and  disadvantages 
of  hemorrhage,  secondary  infection,  tracheal  fistula,  stricture  of  the 
larynx,  delayed  convalescence  from  a  slowly  healing  wound,  and  a 
disfiguring  cicatrix;  and  another  group  of  physicians,  who,  though 
recommending  intubation  in  preference  to  tracheotomy,  are  neverthe- 
less quite  timid  in  accepting  it  as  the  operation  of  choice  in  all  cases 
of  laryngeal  stenosis.  They  lay  particular  stress  upon  the  risk  of  the 
tube  causing  ulceration  of  the  larynx,  or  the  danger  of  return  or  in- 
crease of  the  dyspnea,  either  by  pushing  false  membrane  before  the 
tube  or  blocking  it  while  in  the  larynx,  and  also  of  expulsion  of  the 
tube  by  coughing  or  otherwise.  Now,  we  do  not  at  all  hesitate  to  say 
that  those  who  claim  intubation  to  be  a  dangerous  operation  never  had 
the  opportunity  or  inclination  to  learn  the  operation  under  the  guid- 
ance of  a  competent  instructor,  nor  have  they  given  it  a  fair  trial.  In 
the  many  years  of  experience  with  intubation  we  have  never  met  with 
the  aforementioned  difficulties,  and  believe  that  this  is  due,  first,  to  the 
fact  that  with  the  early  administration  of  antitoxin  the  virulent  types 
of  diphtheria  of  olden  times  are  of  very  exceptional  occurrence  now- 
adays; and  secondly,  to  the  care  and  scrutiny  in  the  selection  of  the 
cases  and  strict  attention  to  the  principles  and  technic  as  handed  down 
to  us  by  the  late  Dr.  O'Dwyer. 

To  begin  with,  we  must  be  absolutely  positive  that  the  cases  in  ques- 
tion actually  require  intubation.  On  several  occasions  we  have  been 
invited  to  intubate  children  who,  instead  of  suffering  from  laryngeal 
stenosis,  were  in  reality  in  the  last  stages  of  pulmonary  edema,  com- 
plicating pulmonary  or  cardiac  disease.  Recently  I  was  called  to  in- 
tubate a  fifteen  months  old  infant  supposedly  dying  from  diphtheritic 
laryngeal  stenosis.  The  baby  did  have  tonsillar  diphtheria,  but  no 
trace  of  laryngeal  involvement,  the  noisy  breathing  having  been  due  to 
intense  dyspnea  accompanying  myocardial  disease.  I  declined  to  in- 
tubate, and  advised  heart  stimulants.  The  parents  of  the  child,  how- 
ever, could  not  be  reconciled  to  this  view,  seeing  that  the  **baby 
was  choking,"  hence  insisted  upon  getting  a  throat  specialist  to  in- 
tubate. This  was  done  two  hours  later,  with  the  result  that  the  baby 
died  during  the  operation. 

The  next  point  of  importance  before  proceeding  with  intubation 
is  to  be  certain  that  the  instruments  are  in  perfect  working  order.* 

*A  set  of  intubation  instruments  (0'I>wyer's)  suitable  for  children  up  to  the  age  of  Duberty 
consists  of  six  tubes,  an  introducer,  an  extractor,  a  mouth  gag,  and  a  scale  of  sizes.  O'Dwyer's 
latest  tubes  are  made  of  hard  rubber  lined  with  gold-plated  metal.  Each  tube  is  supplied  with 
an  obturator,  one  end  of  which  screws  on  the  introducer.  The  tube  is  selected  according  to 
the  age  of  tlie  patient- — the  smallest  size  for  the  first  year,  the  second  for  the  second  year,  the 
third  for  from  two  to  four  years,  and  the  others,  successively  for  children  two  years  older.  It 
should  be  remembered  that  the  tube  must  fit  the  larynx  and  the  latter  not  be  made  to  fit  the  tube. 


378 


DISEASES   OF    CHILDREN 


Particular  attention  should  be  paid  to  the  construction  and  condition 
of  the  tube,  more  particularly  that  it  be  free  from  rough  or  sharp  metal 
edges;  otherwise,  when  during  the  act  of  swallowing  the  epiglottis  and 
upper  end  of  the  tube  are  pushed  posteriorly  by  the  backward  pressure 
of  the  base  of  the  tongue,  and  the  lower  end  of  the  tube  is  pressed 
forward,  the  gliding  movement  of  the  rough  tube  is  very  apt  to  in- 
jure the  anterior  wall  of  the  trachea  and  thus  to  produce  the  ulcera- 
tion of  the  larynx  previously  spoken  of.  We  must  also  note  that  the 
obturator  fits  snugly,  and  that  the  tube  selected  corresponds  to  the  size 
of  the  child's  larynx. 

After  having  ascertained  these  details  to  our  entire  satisfaction  we 
may  then  proceed  with  the  operation.  The  patient  is  placed  upon  a 
strong  table,  and,  from  shoulders  down,  wrapped  tightly  in  a  small 


Fig.  88. — ^Instruments  for  intubation.      (Dr.  O'Dwyer's.) 


sheet  or  blanket,  fastened  by  several  strong  safety  pins.  An  assistant 
standing  at  the  head  of  the  table  inserts  a  mouth  gag  in  the  left  angle 
of  the  child's  mouth,  well  back  between  the  teeth,  and  opens  the  gag 
as  wide  as  possible  without  using  undue  force.  The  same  assistant 
steadies  the  patient's  head  and  holds  the  gag  in  place.  The  operator, 
standing  to  the  right  and  in  front  of  the  patient,  holds  the  introducer 
lightly  between  thumb  and  fingers  of  the  right  hand,  with  the  thumb 
resting  just  behind  the  button  that  serves  to  detach  the  tube,  and  the 
index  finger  in  front  of  the  trigger  underneath.  The  index  finger  of 
the  left  hand  is  now  gently  passed  into  the  pharynx,  down  to  the 
beginning  of  the  esophagus,  and  by  bringing  the  finger  forward  in  the 
median  line  and  raising  and  fixing  the  epiglottis,  the  tube  (threaded 


SPECIFIC    COMMUNICABLE   DISEASES 


379 


with  silk  to  prevent  it  from  slipping  into  the  stomach  in  case  it  is 
wrongl}'  put  into  the  esophagus)  is  gently  introduced  along  the  left 
index  finger  into  the  larynx.  The  left  index  finger  is  then  quickly 
put  on  the  shoulder  of  the  tube,  and  the  introducer  (with  obturator) 
is  withdrawn  after  pushing  its  upper  button  forward.  After  the  tube 
has  been  securely  pushed  home  the  mouth  gag  is  removed,  but  the 
silk  thread  is  left  in  the  tube  for  about  ten  minutes,  until  it  has  been 
ascertained  that  the   dyspnea   is   relieved   and   no   loose   membrane   is 


Fig.  89. — Mode  of  feeding  after  intubation. 


crowded  down  in  the  lower  portion  of  the  trachea.  In  removing  the 
thread,  the  finger  should  be  reinserted  to  hold  the  tube  in  place.  As 
a  rule,  introduction  is  followed  by  an  active  spell  of  coughing,  which 
generally  expels  mucus  and  bits  of  membrane  that  may  have  been 
lodged  in  the  upper  respiratory  tract.  Should  we  fail, -however,  to 
relieve  the  dyspnea,  it  is  advisable  to  remove  the  tube  immediately  by 
pulling  the  thread,  to  induce  emesis  and  expulsive  coughing  by  tick- 
ling the  child's  palate  and  throat  with  spoon  or  finger,  and  then  to  re- 
introduce the  tube,  or,  if  the  case  be  very  urgent,  to  use  a  smaller  tube 


380  DISEASES   OF    CHILDREN 

temporarily.  There  is  never  any  danger  in  repeated  intubation,  or 
even  failure  to  intubate,  provided  the  operation  is  performed  very 
gently — more  particularly  so  as  not  to  force  a  false  passage — and  the 
index  finger  is  not  allowed  to  rest  upon  the  upper  portion  of  the  lar- 
ynx too  long,  so  as  to  obstruct  the  air  passage. 

The  after  treatment  consists  in  keeping  the  patient  quiet,  preferably 
in  a  recumbent  posture,  application  of  an  ice  collar  around  the  neck, 
and  administration  of  antitoxin  (if  needed)  and  small  doses  of  bro- 
mide, strychnine,  and  strophanthus.  Feeding  may  be  resumed  a  few 
hours  after  intubation:  in  babies,  breast  or  cow's  milk  in  small  quan- 
tities, by  means  of  a  spoon;  in  older  children,  semisolid  substances, 
such  as  custards,  wine  jelly,  junket,  soft-boiled  egg,  ice  cream,  and  the 
like.  Small  pieces  of  ice  may  be  given  instead  of  water.  It  is  often 
of  advantage  to  feed  the  child  with  the  head  lower  than  the  body 
(Fig.  89). 

With  the  absolute  subsidence  of  the  dyspnea  and  temperature, 
which  usually  occurs  in  from  three  to  seven  days,  we  may  proceed  with 
extubation.  It  is  always  advisable  to  have  another  tube  ready  for 
immediate  reintubation  in  case  removal  of  the  tube  is  followed  by 
return  of  intense  dyspnea.  For  extubation  the  patient  is  prepared  in  the 
same  manner  as  for  intubation.  The  extractor  is  guided  along  beside  the 
left  index  finger  in  the  same  manner  as  the  intubator  and  very  gently 
inserted  into  the  aperture  of  the  tube.  The  engaging  terminal  blades 
of  the  extractor  are  opened  by  lightly  pressing  upon  the  upper  arm  of 
the  extractor,  and  the  latter  is  then  promptly  withdrawn  from  the 
throat.  This  maneuver  is  not  always  easy,  but  even  repeated  fail- 
ure will  do  no  harm,  provided  no  force  be  employed.  Occasionally 
one  succeeds  in  removing  the  tube  by  "stripping"  the  larynx  from 
below  upward  with  one  hand,  at  the  same  time  grasping  the  head  of 
the  tube  between  the  index  and  middle  fingers  of  the  other  hand. 

As  a  rule,  these  procedures  end  the  operation.  On  rare  occasions, 
however,  there  is  an  immediate  return  of  the  asphyxia.  In  this  event, 
unless  the  dyspnea  resumes  extraordinary  gravity,  we  may  administer  an 
emetic  (apomorphine)  or  minute  doses  of  morphine  and  atropine  hy- 
podermically,  and  spray  the  throat  with  a  1  or  2  per  cent  solution  of 
cocaine  until  the  spasmodic  stenosis  has  been  relieved. 

I  recall  but  two  instances  where  I  was  obliged  to  reintubate  three 
times,  and  one  of  them  failed  to  show  diphtheria  bacilli  in  the  throat 
after  repeated  laboratory  examinations.  In  these  cases,  which  are 
generally  spoken  of  as  ''retained  intubation  tubes,"  we  usually  rem- 
edy the  trouble  by  gradually  introducing  larger  tubes  (anointed  with 


SPECIFIC    COMMUNICABLE   DISEASES  381 

vaseline)  with  each  reiiitubatioii  and  by  local  attention  to  the  nose  and 
throat. 

To  counterpoise  the  admonition  frequently  given,  ''never  to  intubate 
patients  who  are  extremely  asphyxiated"  (E.  W.  Goodall,  Intern.  Med. 
Ann.,  1907),  Ave  may  be  permitted  to  relate  the  following  instructive 
experience : 

J.  D.,  five  and  a  half  years  old,  had  been  coughing  croupy  for  three  or  four 
days,  and,  as  the  parents  were  poor,  was  treated  by  them  with  the  usual  home  reme- 
dies. In  the  middle  of  the  night  his  condition  became  so  alarming  that  they  hurried 
for  a  neighboring  physician.  Finding  that  the  boy  was  suffocating  from  diphtheritic 
laryngeal  stenosis,  the  doctor  promptly  summoned  me  to  perform  intubation.  As  I 
entered  the  dingy  and  foul-smelling  room  I  was  greeted  with,  "  It  is  too  late,  Doctor. ' ' 
Indeed,  the  boy  was  actually  in  the  last  stage  of  asphyxia,  his  face  bluish  black,  his 
eyes  protruding  and  suffused,  his  breathing  suspended,  and  his  entire  body  per- 
fectly limp — apparently  dead  but  for  a  barely  audible  fluttering  of  his  heart.  I 
remarked  to  my  colleague  that  since  we  were  not  going  to  be  paid  for  our  visit 
anyhow,  we  might  as  well  gain  something  from  the  additional  practice  in  intubation. 
Thereupon  I  quickly  inserted  a  tube  in  the  boy's  larynx,  carried  him  to  the  front  of 
an  open  window  and  injected  t^q  grain  of  strychnine  hypodermically,  while  Dr.  F. 
proceeded  with  artificial  respiration.  There  was  shortly  a  marked  change  for  the 
better  and  the  child  improved  so  rapidly  that,  after  administering  10,000  units  of  anti- 
toxin, we  were  able  to  leave  him  under  the  care  of  his  mother  within  about  an  hour 
after  our  arrival.  I  extubatcd  six  days  later,  and  the  boy  recovered  fully  without  any 
further  attention. 

Tracheotomy 

This  operation  is  indicated  where  intubation  fails  to  give  relief, 
whenever  the  larynx  is  obstructed  by  foreign  bodies,  edema  of  the 
glottis,  tumors  {e.g.,  multiple  laryngeal  papillomas,  or  compression  by 
tumors  of  neighboring  structures)  and  cicatricial  constriction  of  the 
larynx.  Unless  there  be  enlargement  of  the  thyroid,  the  low  operation 
is  to  be  preferred,  and,  according  to  Donald  Guthrie,  may  be  performed 
without  loss  of  blood,  if  the  directions  here  given  are  followed : 

The  child  is  wrapped  in  a  blanket  or  sheet  to  control  its  struggling  and 
placed  on  the  table.  A  pad  of  some  sort  is  put  under  the  shoulders,  and 
the  head  is  hung  over  the  end  of  the  table— steadied  by  an  assistant. 
The  operator  stands  at  the  right  hand  side  of  the  child  and,  steadying 
the  skin  with  the  left  hand,  makes  an  incision  in  the  midline  of  the  neck 
from.  11/2  to  13/4  inches  long.  The  skin  and  the  superficial  fascia  are 
incised  and  the  wound  is  held  open  by  a  pair  of  catspaw  retractors  which 
should  not  be  more  than  an  inch  in  breadth.  When  the  deep  cervical 
fascia  is  cut,  the  parallel  branches  of  the  anterior  jugular  veins  are  seen 
in  the  wound.  The  retractors  are  reset  to  pull  these  veins  aside,  and  the 
sternohyoid  and  sternothyroid  muscles  are  separated  by  blunt  dissection. 


382 


DISEASES   OF    CHILDREN 


If  care  can  be  exercised  during  this  step  of  the  operation,  the  muscles 
can  usually  be  separated  without  injury  to  the  thyroid  ima  beneath. 
The  retractors  are  again  reset,  the  left  blade  holding  aside  the  skin,  the 
fascia  and  the  two  muscles,  and  the  right  blade  the  skin,  fascia,  the  mus- 
cles and  the  thyroid  ima  vein.  This  exposes  the  trachea  to  view.  It  is 
incised,  the  child's  head  is  straightened,  and  the  tracheotomy  tube  in- 


Fig.  90. — Trai'.heotomy  tube. 

serted.  The  tube  should  be  removed  from  time  to  time  in  order  to  deter- 
mine if  the  child  can  obtain  a  sufficient  supply  of  air  through  the  larynx. 
When  this  is  achieved  the  tube  is  removed  for  good. 


Scarlatina 

(Scarlet  Fever,  Febris  Rubra) 

The  more  frequently  one  has  occasion  to  observe  and  to  treat  scar- 
let fever,  the  more  he  appreciates  the  treacherous  nature  of  the  affection. 
Grave  danger  often  lurks  in  the  most  benignly  appearing  attack,  and 
dreadful  surprises  are  not  rarely  encountered  at  a  time  when  the  pa- 
tient is  apparently  at  the  threshold  of  recovery.  It  may  be  so  mild  in 
one  child  as  to  entirely  escape  observation,  and  yet  may  give  rise  to 
a  most  virulent  type  of  the  disease  in  another  child.  It  is  highly  con- 
tagious and  infectious  in  all  its  stages,  the  contagium  (which  is  still 
unknown)  being  transmitted  from  person  to  person,  through  a  third 
person,  disease  carrier,  articles  in  use,  toys,  food  (infected  milk),  and 
possibly  also  through  the  air.  Children  of  from  two  to  seven  years  are 
especially  prone  to  contract  the  disease,  but  it  has  been  observed  even 
in  the  newborn  of  mothers  suffering  from  scarlatina  just  before  de- 
livery, and  also  in  adults.  It  prevails  principally  during  the  winter 
months.  So-called  surgical  scarlatina  is  occasionally  contracted  after 
severe  burns  or  surgical  operations.    As  in  other  contagious  and  infec- 


SPECIFIC    COMMUNICABLE   DISEASES 


383 


Chart  II 


384  DISEASES   OF    CHILDREN 

tious  diseases,  some  individuals  possess  an  inherent  or  acquired  tempo- 
rary or  permanent  immunity  against  this  disease.  On  the  other  hand, 
some  children  are  highly  susceptible  to  scarlatina  and  may  have  two 
or  three  attacks,  sometimes  even  in  the  form  of  a  relapse  within  from 
two  to  six  weeks  after  the  first  attack   {scarlatina  recurrens). 

The  incubation  period  of  scarlet  fever  is  ordinarily  shorter  than  that 
of  any  other  exanthematous  febrile  disease.  As  a  rule,  it  lasts  only  a 
few  days  (varies  from  one  day  to  one  or  two  weeks),  and  rarely  gives 
rise  to  distinct  symptoms  of  the  approaching  disease.  On  the  contrary, 
often  in  the  midst  of  apparently  good  health,  the  patient  vomits  (usu- 
ally repeatedly),  complains  of  fatigue,  slight  sore  throat,  and  chilliness; 
and  young  nervous  children  are  occasionally  attacked  by  convulsions. 
The  temperature  rises  up  to  103°  or  104°  F.,  or  higher;  the  pulse  is 
greatly  accelerated ;  the  throat  is  deeply  injected ;  the  tonsils  are  some- 
what enlarged  and  covered  with  a  slight  mucopurulent  or  hemorrhagic 
deposit.  Sometimes  a  transient,  prodromal  erythema  is  observed  on  dif- 
ferent portions  of  the  body.  The  aforementioned  symptoms  continue 
for  about  twenty-four  hours.  By  this  time,  or  a  few  hours  later,  a  bright 
red  rash  becomes  visible  on  the  neck,  chest  and  nates  and  the  flexor 
surfaces  of  the  extremities.  On  close  examination  the  eruption  is  found 
to  consist  of  very  fine,  rose-red  to  deep-red  dots  separated  by  minute, 
pale  areas  of  healthy  skin.  The  scarlet  points  are  not  elevated  above  the 
surface.  The  rash  disappears  on  pressure,  and  when  the  finger  nail  or 
a  pencil  is  drawn  across  the  reddened  surface,  a  white  line  (t aches  scarla- 
tinale)  develops  which  remains  in  situ  for  a  few  seconds.  This  is  due 
to  increased  contractility  of  the  superficial  arterioles.  Or  if  a  tight  band 
is  put  around  the  upper  arm  we  may  shortly  notice  minute  linear  hem- 
orrhages at  the  bend  of  the  elbow  (Rumpel-Leede  sign).  Gradually  the 
scarlatinal  eruption  spreads  usually  from  above  downw^ard  over  the  en- 
tire body.  It  is  least  marked  upon  the  face,  and  the  circumoral  ring — 
a  space  extending  from  the  alae  nasi  to  the  chin — is  nearly  always  free 
from  the  exanthema.  The  affected  skin  is  very  itchy  and  often  edema- 
tous. "With  the  advent  of  the  eruption  the  temperature  rises,  the  sub- 
maxillary glands  swell  up,  are  hard  and  painful  to  the  touch.  Inspec- 
tion of  the  throat  in  the  majority  of  cases  reveals  a  follicular  deposit 
upon  the  tonsils  which  shows  a  tendency  to  coalesce  and  to  form  necrotic 
patches.  The  tongue  is  coated,  very  gray,  and  its  edges  and  tip  are 
bright  red.  The  papillae  fungiformes  soon  project  through  the  coating 
as  red  papules — ' '  strawberry  tongue. ' '  In  accord  with  the  height  of  the 
temperature,  the  patient  is  more  or  less  thirsty,  restless,  delirious,  re- 
fuses food,  sometimes  vomits ;  his  urine  is  scanty,  high  colored,  and  usu- 
ally contains  a  trace  of  albumin.    The  symptoms  thus  far  related  repre- 


PLATE  VIII 
Angina  Scarlatinosa  and  "Strawberry  Tongue" 

(Courtesy  of  Dr.  Joint  Zahorsky.) 


SPECIFIC    COMMUNICABLE   DISEASES 


385 


sent  the  clinical  pictnre  of  typical  scarlatina  dnring  the  first  two  or 
three  days  of  the  eruptive  stage.  As  the  disease  advances  the  gray  de- 
posit on  the  tongue  is  cast  off,  the  entire  tongue  is  more  or  less  swollen, 
red,  often  fissured,  and  covered  with  thickened  papillae.  The  deposit  in 
the  throat  loses  its  tenacity,  and  sometimes  falls  off  en  masse,  leaving  be- 
hind raw,  sometimes  bleeding  surfaces.  The  pulse  and  temperature 
(103  to  105°  F.)   continue  quite  high.     Cases  of  considerable  severity 


DATE 

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104 

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— 1 — 

Fig.  91. — Fever  curve  of  a  case   of   scarlet  fever. 

present  in  addition  marked  debility;  febrile,  cardiac,  systolic  murmurs; 
slight  enlargement  of  the  liver  and  spleen  and  at  times  somnolence,  delir- 
ium, with  or  without  high  temperature.  On  the  other  hand,  mild  cases 
by  this  time  (fifth  day)  may  be  on  the  road  to  recovery,  free  from  fever 
and  rash,  the  patients  being  ready  to  be  around  and  about. 

The  stadkmi  desquamativmn  usually  sets  in  four  or  five  days  after  the 
appearance  of  the  eruption,  and  depends  somewhat  upon  the  intensity  of 
the  exanthema,  beginning  earlier  when  the  rash  is  pronounced.    The  peel- 


386  DISEASES   OF    CHILDREN 

ing  may  vary  from  fine  branny  scales  to  large  patches  of  epidermis,  the 
coarser  scales  being  usually  limited  to  the  hands  and  feet.  Occasionally 
the  nails  shed  with  the  epidermis.  The  peeling  may  last  from  two  weeks 
to  as  many  months,  or  even  longer.  In  uncomplicated  cases  desquama- 
tion is  followed  by  decline  of  the  symptoms  and  convalescence. 

Complications  are  quite  frequent,  and  their  appearance  is  usually 
manifested  by  recrudescence  of  the  temperature  after  defervescence. 
Scarlatinal  angina — a  necrotic  inflammation  of  the  throat — heads  the 
list.  It  is  caused  by  streptococcic  infection  and  differs  clinically 
from  true  diphtheria  in  that  it  almost  never  sjDreads  to  the  larynx 
nor  causes  paralysis.  Occasionally  it  is  associated  with  true  diph- 
theria. 

The  throat  involvement  may  be  grave  right  from  the  beginning 
of  the  scarlatina,  but  more  frequently  it  develops  between  the  third 
and  fourth  days,  usually  in  the  form  of  an  aggravation  of  the  previous 
condition.  The  glands  at  the  angles  of  the  jaws  swell  at  times  enor- 
mously, are  very  hard  and  tender.  Inspection  of  the  throat  reveals  a 
large  yellow  or  gray  exudate  on  the  greatly  enlarged  tonsils,  and  often 
also  on  the  posterior  pharyngeal  wall.  Scarlatinal  angina  often  extends 
also  to  the  nose,  giving  rise  to  a  fetid,  brownish-yellow  discharge, 
and  occasionally  to  deeper  destructive  processes  and  even  to  necrosis 
of  the  nasal  bones.  Scarlatinal  angina  is  a  very  malignant  affection, 
and  frequently  leads  to  fatal  termination  as  a  result  of  gangrene 
of  the  throat,  involvement  of  the  neighboring  blood  vessels,  purulent 
inflammation  of  the  serous  membranes  (pleura,  pericardium  and  men- 
inges), extreme  prostration,  and  general  pyemia.  In  some  epidemics 
one  is  able  to  distinguish  two  additional  types  of  angina :  1.  The 
"pestilential  form,"  characterized  by  mucopurulent,  foul  masses  in  the 
throat  and  nose,  spreading  of  the  gangrenous  process  to  the  mouth  and 
the  mucous  membrane  of  the  lips  and  cheeks  with  consecutive  hemor- 
rhage, septicopyemic  symptoms,  increasing  collapse,  and  fatal  termina- 
tion within  about  one  week.  2.  ''Lentescent  scarlatinal  diphtheroid," 
which  sets  in  about  the  sixth  day  of  the  disease  with  sudden  rise  of 
temperature,  grave  constitutional  symptoms  and  intense  swelling  of 
the  submaxillary  glands.  The  local  symptoms  (which,  by  the  way,  are 
sometimes  hidden!)  in  the  nose  and  throat  resemble  those  of  true 
diphtheria,  except  that  in  scarlet  fever  there  is  a  greater  tendency  to 
necrosis  of  the  affected  portions,  and  to  perforation  of  the  palate  (as 
in  syphilis).  After  stubborn  persistence  it  quite  frequently  leads  to 
fatal  issue  with  symptoms  of  pyemia  and  asthenia.  True  diphtheria 
may  be  associated  with  any  of  the  aforementioned  forms  of  scarlatinal 
angina.     An   examination   of  the   deposit   for  Klebs-Loffler   bacillus, 


SPECIFIC    COMMUNICABLE   DISEASES  387 

therefore,  is  always  opportune.  Purulent  otitis  frequently  arises 
as  an  immediate  sequel  of  the  nasopharyngeal  involvement  by  extension 
of  the  inflammation  through  the  Eustachian  tube  and  tympanic  cavity. 
It  is  manifested  by  the  usual  symptoms  of  otitis  media:  earache,  rest- 
lessness, rise  of  temperature,  congestion  and  bulging  of  the  drum  mem- 
brane, and,  as  a  rule,  rapid  perforation  of  the  drum  by  the  pus.  In 
a  great  many  cases  the  otitis  leaves  no  serious  consequences  behind ; 
in  some  of  them,  hovv^ever,  especially  in  those  in  which  the  escape  of 
pus  is  delayed,  scarlatinal  otitis  may  lead  to  very  grave  consequences, 
such  as  deafness  (in  very  young  children  deaf-mutism)  mastoiditis, 
meningitis,  etc. 

Another  serious  sequel  of  the  throat  affection  is  angina  Ludovici, 
an  inflammation  of  the  submaxillary  lymph  glands  and  the  surround- 
ing cellular  tissue  of  the  neck,  extending  from  the  submental  region 
up  to  the  mastoid  process  of  the  temporal  bone.  The  inflammatory 
infiltration  sometimes  extends  to  the  larynx  and  produces  edema  glot- 
tidis,  and,  by  gravitation,  the  pus  may  enter  the  mediastinum  and 
neighboring  structures  (leading  to  purulent  pleurisy  or  pericarditis). 
It  not  rarely  ends  fatally  with  symptoms  of  septicemia,  embolism  or 
thrombosis. 

Among  the  earlier  complications  of  scarlatina  we  may  mention 
also  pneumonia  with  or  without  pleurisy,  rheumatism  (myositis,  syno- 
vitis) and  endocarditis.  All  of  these  complications  are  probably  of 
septic  origin.  The  pneumonia  presents  nothing  characteristic,  may 
be  lobular  or  lobar  in  type.  It  usually  runs  a  shorter  course  than 
primary  pneumonia.  Scarlatinal  rheumatism  occurs  in  two  forms : 
Simple  myositis,  i.  e.,  a  localized  muscular  infiltration,  with  sensitive- 
ness on  pressure,  and  vague  "wandering"  pain;  and  scarlatinal  syno- 
vitis or  arthritis  which  is  manifested  by  pain,  swelling  and  redness 
of  the  joints,  especially  those  of  the  fingers  and  toes,  rise  of  tempera- 
ture, and  other  constitutional  symptoms.  Sometimes  several  joints 
are  affected  by  leaps.  As  a  rule,  scarlatinal  rheumatism  is  benign 
in  nature;  occasionally,  however,  the  joints  may  undergo  suppuration, 
leading  to  general  pyemia  with  fatal  termination. 

In  association  with  scarlatinal  rheumatism,  but  often  also  without 
this,  endocarditis  forms  a  relatively  frequent  complication  and  sequel 
scarlatina.  Indeed,  the  majority  of  cases  of  valvular  heart  disease  in 
children,  except,  of  course,  those  complicating  primary  rheumatic  fever, 
are  traceable  to  scarlatina.  The  endocarditis  may  at  first  be  latent, 
and  escape  detection,  and  again,  may  usher  in  with  very  grave  symptoms, 
run  the  course  of  ulcerative  endocarditis,   giving  rise  to  emboli   and 


388  DISEASES   OF   CHILDREN 

metastases  in  the  liver,  spleen,  and  kidneys,  and  end  in  sndden  death 
or  permanent  valvnlar  heart  disease. 

The  blood  shows  a  prononneed  lencoeytosis,  a  marked  increase  of 
eosinophiles  (up  to  15  or  20  per  cent  of  all  white  cells)  and,  in  se- 
vere eases,  streptococci. 

The  treacherous  nature  of  scarlatina  is  most  poignantly  illustrated 
by  the  occurrence  of  nephritis  as  a  complication.  In  the  midst  of 
apparently  perfect  health,  at  a  time  when  the  eruption  has  entirely 
subsided,  either  with  or  wnthout  any  tangible  cause  (often  after  a 
slight  error  in  the  diet),  the  child  is  suddenly  attacked  by  head- 
ache, dizziness,  sometimes  vomiting  and  convulsions,  and  examination 
of  the  urine  reveals  an  interstitial  inflammation  of  the  kidneys.  As 
the  disease  advances  the  symptoms  enumerated  under  ''nephritis" 
{q.  V.)  are  rapidly  and  fully  established.  The  complication  usually  oc- 
curs between  the  end  of  the  second  and  third  weeks.  Hence  the  im- 
portance of  daily  examination  of  the  urine  in  all  cases  of  scarlatina, 
irrespective  of  the  type  or  degree  of  severity  of  the  disease.  The  dura- 
tion of  the  nephritis  varies  greatly  according  to  its  severity,  and  the 
promptness  with  which  it  is  discovered  and  treated.  Ordinarily  it 
lasts  from  two  to  four  weeks  and  ends  favorably,  but  relapses  are  not 
rare,  and  the  nephritis  may  go  on  to  chronic  renal  disease.  In  fact, 
scarlet  fever,  as  a  rule,  forms  the  principal  cause  of  chronic  nephri- 
tis in  children.  Protracted  scarlatinal  nephritis  often  gives  rise 
to  hypertrophy  of  the  left  ventricle  and  occasionally  also  to  dila- 
tation of  the  heart  with  consecutive  symptoms  of  ruptured  compensa- 
tion (recurrent  anasarca,  dyspnea,  etc.).  Genuine  scarlatinal  neph- 
ritis should  not  be  confounded  with  the  transient  albuminuria  not 
rarely  observed  during  the  first  week  of  scarlatina,  and  which  most 
probably  is  due  to  hyperpyrexia.  As  regards  uremia,  and  its  grave 
accompaniments,  the  reader  is  referred  to  "acute  nephritis''  (q.v.). 

More  rare  complications  are  the  following:  stomatitis  ulcerosa  and 
aphthosa,  noma,  gangrene  and  diphtheria  of  the  genitalia,  orchitis, 
vaginitis,  gangrene  of  the  skin  and  of  the  tapering  extremities;  various 
nervous  disorders,  such  as  meningitis,  hemiplegia,  aphasia,  tetany,  and 
psychoses;  conjunctivitis,  iritis,  keratitis,  choroiditis,  neuroretinitis, 
retinitis  albuminurica  and  sudden  amaurosis  (in  one  of  our  cases  total 
amaurosis  lasted  over  a  week). 

Aside  from  the  sequelae  previously  spoken  of,  scarlatina  may  be 
productive  also  of  chronic  purpura,  chronic  cutaneous  affections  (fu- 
runculosis),  chorea,  paralyses,  marasmus,  tuberculosis,  etc. 

For  the  differential  diagnosis  see  Table,  p.  398. 


SPECIFIC    COMMUNICABLE    DISEASES  389 

The  discussion  of  the  subject  in  question  thus  far  relates  prin- 
cipally to  cases  of  scarlatina  of  ordinary  severity.  In  these  cases  the 
diagnosis  is  usually  quite  easy,  and  the  prognosis,  except  in  the  pres- 
ence of  serious  complications,  relatively  favorable.  We  shall  now  en- 
deavor to  emphasize  some  of  the  numerous  atypical  forms. 

Occasionally  scarlatina  is  associated  "with  an  atypical  eruption.  In- 
stead of  the  fine  scarlet  rash  there  may  be  variously  sized  papules  or 
wheals  upon  a  reddened  base;  minute  vesicles  {scarlatina  miliares)  or 
pemphigus-like  blebs.  The  exanthema  sometimes  evolves  gradually,  re- 
quiring several  days  instead  of  hours  as  is  the  case  in  typical  scarlatina. 
The  rash  may  appear  localized  with  intervening  larger  portions  of  nor- 
mal skin  (scarlatina  variegata) .  Finally,  there  may  be  genuine  scarla- 
tina, with  typical  angina,  nephritis,  and  even  slight  desquamation,  with- 
out any  exanthema  (scarlatina  sine  exanthema).  The  diagnosis  in  all 
such  cases  is  extremely  difificult,  and  sometimes  impossible,  unless  at  the 
same  time  typical  scarlatina  prevails  in  the  immediate  surroundings,  and 
the  other  symptoms  point  strongly  toward  this  disease. 

The  course  of  the  attack  also  may  present  great  variations.  It  may 
be  so  ver}^  mild  and  brief  as  to  escape  observation,  or  run  a  mild,  but 
protracted  course,  and  remain  free  from  complications.  In  the  latter 
group  of  cases  the  temperature  may  be  low,  or  remittent,  with  evening 
remissions  and  morning  exacerbations  (typus  inversus).  Fever  may 
be  absent  entirely  even  in  severe  cases.  Sometimes  the  temperature  is 
very  high  (Jiyperpyretic  scarlatina)  from  the  beginning,  giving  rise 
to  delirium,  convulsions,  etc.,  but  subsides  again  after  a  few  days,  leav- 
ing the  patient  apparently  unharmed.  At  other  times,  very  high  tem- 
perature is  characteristic  of  malignant  scarlet  fever. 

Scarlatina  maligna,  gravissima  s.  fulminans,  fortunately  is  not  of 
very  frequent  occurrence.  In  the  majority  of  instances  the  grave 
manifestations  are  in  full  bloom  within  the  first  twenty-four  hours  of 
the  onset  of  the  attack.  The  child  is  suddenly  seized  with  vomiting, 
rigors,  delirium  or  convulsions,  the  temperature  rises  to  106°  F.  or 
even  higher.  The  pulse  is  weak,  rapid  and  irregular.  Sudden  collapse, 
coma,  eclampsia  and  death  follow  in  rapid  succession  (often  within 
twenty-four  hours).  In  another  group  of  cases  the  course  is  more  pro- 
tracted, and  typhoid  in  character.  The  temperature  is  not  as  high  as 
in  the  aforementioned  class,  but  is  marked  by  evening  exacerbations; 
the  tongue  is  dry,  the  lips  and  teeth  are  covered  with  sordes,  the  ab- 
domen is  very  tympanitic,  and  the  stools  are  watery.  The  submaxillary 
glands  are  enormously  enlarged.  There  are  also  signs  of  blood  disso- 
lution, extensive  hemorrhages  from  the  nose,  gums,  and  stomach,  which 
greatly  enhance  the  (fatal)  exhaustion.     The  rash  is  usually  of  a  vio- 


390  DISEASES   OF    CHILDREN 

let  color  and  hemorrhagic  spots  are  scattered  over  the  surface  of  the 
body.  This  form  of  scarlet  fever  is  often  spoken  of  as  ''septic,  hem- 
orrhagic scarlatina. ' ' 

Appreciating  the  unreliability  of  the  initial  manifestations,  the  un- 
certainty in  the  further  symptomatology,  the  diversity  of  the  course 
of  scarlatina  and  its  great  tendency  toward  grave  complications  and 
sequelffi,  it  is  prudent  always  to  be  very  guarded  in  expressing  an 
opinion  as  to  the  outcome  of  the  disease,  no  matter  how  mild  (or 
severe)  the  attack.  The  mortality  varies  in  different  epidemics,  from 
4  to  40  per  cent,  and  depends  partly  upon  the  age  (it  is  high  in  chil- 
dren under  four  and  over  ten  years  old)  of  the  patient  and  principally 
upon  the  number  and  severity  of  the  complications  and  sequelae. 

Treatment. — In  view  of  the  high  mortality  it  is  essential  to  institute 
prompt  prophylactic  measures  from  the  very  inception  of  an  attack 
of  scarlatina.  Rest  in  bed  is  indispensable  even  in  the  mildest  cases, 
and  should  be  enforced  for  at  least  two  weeks  (much  longer  in  severe 
cases)  from  the  beginning  of  the  illness.  For  about  the  same  length 
of  time  the  diet  should  be  restricted,  avoiding  all  such  articles  of  food 
as  are  apt  to  upset  the  alimentary  canal  and  to  irritate  the  kidneys.  In 
the  active  stage  of  the  disease  the  diet  should  consist  of  milk  only,  and, 
as  the  symptoms  abate,  light  cereals,  and  thin  broths  may  be  added; 
in  older  children  also  small  quantities  of  toasted  bread  and  butter, 
fish  (boiled),  chicken,  soft-boiled  eggs,  and  similar  light  food  —  all 
free  from  salt  and  spices.  Easily  digestible  food  should  be  continued 
for  several  weeks  after  subsidence  of  all  traces  of  the  disease.  These 
procedures  form  the  most  potent  means  of  prevention  of  renal  and 
cardiac  disease. 

In  view  of  the  frequency  of  ear  complications  every  effort  should  be 
made,  firstly  by  cleanliness  of  the  nose  and  throat,  to  prevent  infection 
of  the  Eustachian  tubes,  and  secondly,  infection  arising,  promptly  to 
make  a  free  outlet  to  the  accumulated  discharge.     (See  Otitis,  p.  303.) 

As  regards  isolation,  room  ventilation,  and  disinfection,  see  p.   68. 

It  is  quite  difficult  to  formulate  rules  for  the  active  treatment  of 
the  disease.  Every  case  is  a  law  unto  itself.  We  have  no  specific  to 
combat  the  affection.  Overdosing — but  also  underdosing —  with  medi- 
cines is  to  be  deprecated.  Very  mild  cases  do  best  if  left  alone,  ex- 
cept as  regards  prophylaxis.  The  recent  attempts  to  favorably  influence 
the  course  of  scarlatina  by  means  of  convalescent  serum  are  still  in  the 
experimental  stage. 

The  average  case  being  usually  of  medium  severity,  an  attempt  will 
here  be  made  to  outline  a  mode  of  treatment  which  is  best  suited  to 
meet  ordinary  indications.     The  patient  should  be  put  to  bed  in  a 


SPECIFIC    COMMUNICABLE   DISEASES  391 

well-ventilated  room  (about  68°  F.),  the  diet  restricted  to  moderate 
quantities  of  water  and  a  little  milk— in  the  absence  of  vomiting. 
Since  at  the  onset  of  the  attack  vomiting  is  usually  very  marked, 
no  medication  per  mouth  should  be  prescribed,  except,  perhaps,  a  few 
minute  doses  of  calomel  and  bicarbonate  of  soda.  To  relieve  high 
temperature  and  nervous  irritation,  w^e  order  a  warm  bath  every  three 
hours.  The  baths  have  also  a  very  salutary  effect  upon  the  kidnej^s 
by  enhancing  the  elimination  of  the  scarlatinal  poison  through  the 
skin.  Warm  packs  may  be  given  instead  of  the  baths.  As  soon  as  the 
vomiting  has  ceased,  we  increase  the  quantity  of  nourishment  and  di- 
rect our  chief  attention  to  the  throat.  The  latter  is  swabbed  every  two 
hours  with  from  5  to  30  per  cent  resorcin-alcohol  solution  or  with  the 
following : 


IJ     Acid.  Carbolici 

3  ss 

2.00 

Pulv.  Camphor89 

Eesorcini 

aa  gr.  x 

0.60 

Alcoholis 

3ii 

8.00 

Glycerini 

q.  s.  f  5  ii 

60.00 

M. 

S. — Apply  to  the  diseased  pa 

rts  by  means  of  a 

cotton  swab  every  two 

hours. 

It  is  often  very  useful  also  to  flush  the  throat  several  times  daily 
with  a  warm  boracic  or  bicarbonate  of  soda  solution  (1  dram  to  1  quart 
of  water). 

The  nose  should  be  cleansed  freely  with  Dobells'  solution  or  similar 
antiseptic.  Often  it  \yill  prove  beneficial  to  instill  in  the  nose  once 
daily  a  5  to  10  per  cent  solution  of  the  newer  silver  preparations.  In 
some  cases  the  nose  is  heavily  blocked  with  a  profuse  foul  discharge 
which  greatly  interferes  with  respiration;  in  this  event  relief  may  be 
afforded  by  introduction  of  soft  rubber  catheter  tubing,  reaching 
from  the  nares  down  to  the  posterior  nasopharynx.  If  dysphagia  and 
tonsillar  swelling  are  marked,  we  prescribe  moderate  doses  of  sodium 
salicylate,  or  one  of  the  newer  salicylate  preparations,  and  the  follow- 
ing mixture : 

IJ     Tr.  Ferri  Chloridi 

Tr.  Myrrhae 

Potassii  Chloratis  aa  3  ss        2.00 

Glycerini  q.  s.  f  5  ii      60.00 

M. 

S. — One  teaspoonful  every  three  hours,  for 
child  four  years  old. 

With  the  aforementioned  therapeutic  measures  we  are  ordinarily 
successful  favorably  to  proceed  with  the  case  up  to  the  fifth  day, — 


392  DISEASES    OF    CIIILDRKN 

the  time  when  "scarlatinal  diphtheria"  is  prone  to  appear.  As  it 
is  almost  next  to  impossible  to  differentiate  scarlatinal  from  diphthe- 
ritic angina  withont  a  bacteriologic  examination,  it  is  sonnd  and  safe 
practice  to  administer  diphtheria  antitoxin  in  all  cases  of  severe  angina, 
especially  if  the  exacerbation  of  the  symptoms  occurs  by  the  end  of 
the  first  week  of  the  disease.  We  usually  inject  5,000  units  of  anti- 
toxin at  once  and  repeat  the  dose  as  indications  arise.  In  malignant 
cases  this  can  be  combined  with  antistreptococcus  serum  or  vaccine. 
The  local  and  internal  medicines  should  be  continued,  however,  except 
bathing,  which  should  be  discontinued  as  soon  as  the  temperature  comes 
down  to  100°  F.  The  heart's  action  should  be  carefully  watched,  and 
any  irregularity  or  debility  detected,  promptly  treated  by  means  of 
moderate  doses  of  strychnine,  digitalis  or  strophanthus.  The  latter 
two  preparations  are  particularly  useful  in  secondary  involvement  of 
the  heart  muscle.  With  the  dietary  and  hygienic  precautions  taken  one 
is  seldom  confronted  by  grave  scarlatinal  nephritis.  Ordinarily,  the 
symptoms  are  limited  to  slight  albuminuria  with  occasional  casts  and 
blood  cells,  which  readily  disappear  upon  the  administration  of  a  few 
doses  of  calomel  and  alkaline  diuretics  and  diaphoretics,  or  urotropin 
in  2  to  5  grain  doses  three  times  a  day,  high  flushing  of  the  bowels 
and  a  few  hot  baths.  But,  as  already  suggested,  occasionally  the 
uremic  manifestations  are  extremely  violent  (delirium,  convulsions, 
coma,  etc.),  resisting  all  sorts  of  medication,  and  growing  worse  from 
hour  to  hour.  In  these  uremic  conditions  two  therapeutic  measures 
have  proved  to  us  of  particular  benefit:  (l)Morphine  and  atropine 
hypodermically ;  (2)  lumbar  puncture.  For  a  child  four  years  old  we 
may  administer  1/20  grain  morphine  and  1/500  grain  atropine,  to  be 
repeated  once  or  twice  within  twenty-four  hours.  In  very  bad  cases 
both  of  these  measures  should  be  employed  simultaneously.  Their 
effect  is  often  magical. 

Where  the  uremic  symptoms  are  slight,  bromide  with  or  without 
chloral  per  mouth  or  per  rectum  suffice  to  relieve  the  nervous  symp- 
toms. As  to  the  management  of  protracted  cases  of  nephritis,  see 
"Nephritis". 

Simple  transient  scarlatinal  myositis  calls  for  no  specific  medication. 
On  the  other  hand,  arthritis  demands  prompt  attention,  since  in  the 
majority  of  instances  it  is  a  manifestation  of  sepsis  and  if  left  alone 
is  apt  to  lead  to  general  pyemia.  The  salicylates  internally  and  ich- 
thyol  externally  seem  to  influence  it  very  favorably,  and  where  these 
measures  fail  and  pus  forms  we  should  resort  to  a  free  incision  and 
drainage — but  not  too  hastily.     The  same  holds  true  for  cervical  or 


SPECIFIC    COMMUNICABLE   DISEASES  393 

submaxillary  adenitis  which,  thoU!f?h  assuming"  very  large  dimensions, 
does  not  always  suppurate. 

For  suggestions  as  to  the  treatment  of  the  remaining,  less  common 
complications  of  scarlatina,  the  reader  is  referred  to  the  discussion 
of  the  respective  diseases. 

An  extremely  difficult  problem  confronts  the  attending  physician 
when  called  upon  to  treat  a  case  of  malignant  scarlet  fever.  Do  what 
you  will,  the  treatment  is  seldom  of  any  avail.  Early  administration 
of  polyvalent  antistreptococcic  and  antidiphtheritic  serum  sometimes 
saves  life,  and  should  always  be  employed,  regardless  of  bacteriologic 
findings  in  the  nasopharyngeal  discharges.  The  same  holds  good  for 
lumbar  puncture,  if  meningeal  symptoms  predominate.  High  tem- 
peratures failing  to  yield  to  hot  baths  should  be  reduced  by  cold 
(80°  to  90°  F.)  packs  or  baths.  The  heart  should  be  kept  actively  stim- 
ulated by  strychnine,  strophanthus,  digitalis,  caffeine,  diuretin,  and 
suprarenal  extract,  the  latter  especially  in  hemorrhagic  complications. 

During  convalescence  particular  attention  should  be  paid  to  the  ali- 
mentary tract  and  skin.  The  bowels  should  be  looked  after,  and  stuff- 
ing the  child  with  sweets,  heavy  meats,  and  alcoholic  "tonics"  strictly 
forbidden.  The  patient  should  be  warmly  clad  and  wear  flannel  or  silk 
next  to  the  skin.  Exposure  to  sudden  atmospheric  changes  should 
be  avoided. 

To  facilitate  desquamation,  the  child  should  be  given  a  hot  soap 
bath  every  two  or  three  days  followed  by  oil  inunction  to  prevent 
free  distribution  of  the  scales.  The  following  combination  is  quite 
serviceable,  and  may  be  employed  also  in  the  eruptive  stage  of  the  dis- 
ease to  relieve  itching  and  burning  of  the  skin : — 


Thymolis 

Acid.  Carbolici 

aa  gi-.  X 

0.65 

Aleoholis 

3ii 

8.00 

Glycerini 

q.  s.  f  5  ii 

60.00 

M. 

S. — For  external 

use, 

p.  r. 

n. 

When  desquamation  is  completed  and  there  is  otherwise  no  con- 
traindication, the  patient  may  be  allowed  out  of  doors.  Cod  liver  oil 
with  the  syrup  of  the  iodide  of  iron  and  a  sojourn  at  the  seashore  have 
proved  very  helpful  to  rapid  recovery. 

The  patient  is  ''contagious"  for  at  least  six  weeks  from  the  onset 
of  the  disease,  and  hence  should  not  be  permitted  to  mix  with  other 
children  for  that  length  of  time,  or  longer,  if  desquamation  continues, 
or  discharges  from  the  nose,  throat,  vagina,  etc.,  are  present. 


394  DISEASES   OF    CHILDREN 

The  Fourth  Disease* 

(Dukes'  Disease) 
The  existence  of  this  affection  is  still  awaiting  authoritative  con- 
firmation. Some  authorities  maintain  that  it  is  merely  a  mild  form 
of  measles  or  scarlet  fever.  It  begins  after  an  incubation  period  of 
from  six  to  fourteen  days  or  longer  with  very  mild  febrile  symptoms 
and  an  efflorescence  on  the  face,  including  the  circumoral  ring.  The 
next  day  the  rash  spreads,  grouped  in  a  sort  of  lacework  arrangement, 
to  the  extremities  and  trunk.  The  course  of  the  affection  is  conspic- 
uous by  absence  of  any  severe  symptoms  and  usually  terminates  fa- 
vorably in  from  five  to  eight  days,  without  any  specific  medication. 
Desquamation  is  copious  and  may  last  several  weeks.  Dukes'  disease 
does  not  confer  immunity  against  other  exanthemata. 

Varicella 

(Chickenpox) 

The  identity  of  the  causal  microorganism  of  varicella  is  still  unknown. 
It  is  absolutely  proved,  however,  that  it  has  nothing  in  common  with 
the  infectious  agent  of  smallpox, — hence  an  attack  of  chickenpox  con- 
fers no  immunity  against  the  former  affection.  The  disease  is  com- 
municable from  person  to  person,  through  an  intermediate  person, 
through  fomites,  and  the  air.  Children  of  from  two  to  ten  years  of  age 
are  especially  prone  to  contract  the  disease,  but  it  is  not  rarely  observed 
also  in  very  young  infants,  and  in  children  over  ten,  and  even  adults 
are  not  entirely  exempt  from  it.  One  attack  does  not  confer  absolute 
immunity  against  another  one. 

The  incubation  period  lasts  about  two  weeks,  the  last  few  days 
showing  slight  prodromata.  Occasionally  the  symptoms  of  invasion  are 
moderately  severe.  There  may  be  vomiting,  angina,  conjunctivitis, 
transient  erythema,  considerable  rise  of  temperature  preceded  by  chills, 
and  in  small  children,  convulsions.  The  eruption,  which  appears 
usually  in  small  or  large  crops  without  any  characteristic  grouping 
simultaneously  upon  several  portions  of  the  entire  body  (also  on  the 
scalp  and  the  mucous  membrane  of  the  mouth  and  throat)  is  fully 
established  within  twenty-four  hours.  At  first  the  eruption  appears 
in  the  form  of  slightly  elevated  rose-red  spots,  which  disappear  on 
stretching  the  skin.  Within  a  few  hours  the  center  of  the  spot  turns 
vesicular,  filled  with  a  clear  fluid.  The  spots  attain  the  size  of  a  lentil 
or  pea,  but  they  may  be  larger,  pemphigoid,  and  more  rarely  umbili- 
cated.    On  the  third  day  the  vesicles  usually  collapse  and  desiccate,  and 

*Termed  so,  being  additional  to  the  three  known  diseases:  Scarlatina,  Rubella  and  Rubeola. 
It  was  first  described  by  Dukes  in  1900. 


SPECIFIC    COMMUNICABLE   DISEASES  395 

become  covered  by  brownish-black  crusts.  The  latter  usually  fall 
off  on  the  fifth  or  sixth  day,  leaving  slight  red  spots  which  soon  disap- 
pear. Repeated  recurrences  of  new  crops  of  the  eruption  in  different 
stages  of  development  (papules,  vesicles,  pustules  and  crusts),  some- 
times as  late  as  ten  to  twelve  days  after  the  onset,  are  not  rare  and 
often  serve  of  signal  value  in  the  differentiation  of  varicella  from 
variola,  in  which  latter  disease  the  eruption  remains  uniform  and  sta- 
tionary until  the  final  stage  of  the  disease.  Occasionally  the  vesicu- 
lar content  is  turbid  or  purulent  (usually  as  a  result  of  infection 
by  scratching),  and  when  the  pustules  heal  leave  behind  scars  re- 
sembling "smallpox  pits."  Sometimes  the  vesicles  burst  early  and 
give  rise  to  erosions  and  ulcerations  which,  if  occurring  in  the  larynx, 
may  be  productive  of  attacks  of  dyspnea  and,  exceptionally,  fatal 
laryngospasm.  More  frequently  we  meet,  usually  as  a  result  of  infec- 
tion, with  multiple  ulcerative  and  gangrenous  processes  of  the  skin 
— varicella  gangrenosa — in  which  the  vesicles  terminate  in  deep,  foul- 
smelling  ulcers,  and  extensive  gangrene  of  the  skin.  This  form  of 
chickenpox  is  most  common  in  delicate,  ill-nourished  children  and  is 
apt  to  prove  fatal.  Complications  and  sequelae  in  the  form  of  nephritis — 
nephritis  varicellosa,  pneumonia,  pleuritis,  pemphigus — varicella  hullosa, 
multiple  abscesses,  pyemic  processes  (due  to  staphylococcic  or  strepto- 
coccic infection),  icterus  catarrhalis,  dysentery,  polioencephalitic  mani- 
festations, marasmus  and  even  tuberculosis  are  on  record,  but  they  are 
rather  of  unusual  occurrence.  Finally  varicella  is  occasionally  asso- 
ciated with  other  exanthemas  ( e.  g.,  measles,  scarlet  fever ) .  Very  re- 
cently several  clinicians  have  called  attention  to  a  curious  relationship 
between  varicella  and  herpes  zoster  and  are  inclined  to  the  belief  that  the 
latter  is  an  atypical  manifestation  of  the  chickenpox  virus.  This  view 
is  awaiting  further  confirmation. 

Treatment. — As  a  rule,  varicella  pursues  a  benign  and*l)rief  course, 
free  from  high  temperature,  and  any  other  constitutional  symptoms 
and  rarely  calls  for  any  therapeutic  measures.  Rest  in  bed,  careful 
diet,  and  local  cooling  lotions  (2  per  cent  of  thymol  in  albolene)  or  oint- 
ments (zinc  oxide  with  1  per  cent  salicylic  acid  and  thymol  and  phenol) 
to  relieve  itching  usually  suffice  in  ordinary  cases.  Cleanliness  of  the 
mouth  and  throat  is  important,  as  well  as  attention  to  the  urine.  For  dif- 
ferential diagnosis,  see  Table,  p.  398. 

Variola  Vera.     Varioloid 

(Smallpox) 
The  history  of  smallpox  is  that  of  death  and  destruction.     It  is  es- 
timated  that,   before  Jenner's   discovery   of  prophylactic   vaccination. 


396  DISEASES    OF    CHILDREN 

one  tenth  of  all  the  children  died  of  smallpox.  On  the  other  hand,  with 
vaccination  and  revaceination  rendered  obligatory  in  most  of  the  civil- 
ized countries,  the  occurrence  of  variola  in  a  child  is  almost  unheard  of. 
If  it  ever  does  occur  in  successfully  vaccinated  children,  the  disease  is 
usually  mild,  modified  in  form — varioloid. 

Smallpox  is  an  acute,  highly  contagious  and  infectious,  endemic  and 
epidemic  disease,  characterized  principally  by  an  eruption  that  passes 
through  the  stages  of  papule,  vesicle,  pustule  and  scab,  the  development 
of  the  pustule  being  accompanied  by  a  secondary  fever. 

The  nature  of  the  smallpox  producing  poison  is  still  unknown.  It 
is  undoubtedly  a  microorganism  that  exists  in  the  eruption  and  prob- 
ably also  in  the  blood.  Garnieri  has  described  minute  corpuscles 
which  are  regularly  found  in  the  cells  of  variola  and  vaccinia  pus- 
tules, but  while  they  may  serve  as  a  characteristic  differential  point 
from  varicella  and  other  pustular  eruptions,  they  seem  to  be  of  no 
etiologic  importance.  The  disease  is  most  communicable  during  the 
pustular  and  desquamative  stages — at  which  time  mere  entering  the 
sickroom  is  said  to  infect  one  not  protected  by  vaccination. 

After  an  incubation  period  of  from  nine  to  fifteen  days,  which 
as  a  rule,  is  free  from  any  significant  signs  of  illness,  the  patient  is 
suddenly  seized  by  a  violent  chill,  fever,  severe  pain  in  the  back,  con- 
vulsions, delirium,  prostration,  and  sometimes  collapse  and  death — 
long  before  the  appearance  of  the  eruption.  An  initial  exanthema  may 
appear  at  this  time,  in  the  form  of  an  erythema  or  hemorrhagic  spots, 
upon  the  trunk  and  extremities,  more  particularly  on  the  anterior  sur- 
face of  the  thigh  (the  so-called  Simon's  triangle).  This  mode  of  onset 
and  termination  is  quite  common  in  variola  vera,  afl'ecting  children  un- 
der three  years  of  age.  Some  cases  survive  until  the  appearance  of  a  pap- 
ular exanthema  upon  the  buccal  and  pharyngeal  mucous  membranes, 
and  then  usually  die  from  exhaustion ;  others  again — usually  older 
than  three  years — succumb  to  the  attack  in  the  suppurative  stage,  or, 
rather  rarely,  recover  after  a  painful  and  tedious  convalescence. 

It  is  customary  to  distinguish  three  types  of  variola  vera:  Dis- 
crete, confiuent,  and  malignant  (hemorrhagic). 

Discrete  Form. — After  the  violent  onset,  the  eruption,  consisting 
of  red,  coarse  spots,  appears  during  the  third  day:  first  on  the  fore- 
head and  lips,  then  on  the  head,  trunk  and  arms,  and  last  on  the  legs. 
Pressing  the  hand  over  the  eruption,  the  latter  imparts  the  sensation  of 
velvet.  The  constitutional  symptoms  then  abate,  and  the  patient  feels 
quite  comfortable.  On  the  fifth  day  of  the  disease  the  spots  develop 
into  papules;  on  the  sixth  into  vesicles  which  soon  become  umbilicated. 
On  the  eighth  day  the  vesicles  are  transformed  into  pustules  which 


SPECIFIC    COMMUNICABLE   DISEASES  397 

emit  a  characteristic  odor  and  on  tlie  ninth  day  tluy  become  entirely 
purulent  and  surrounded  by  a  broad  red  band — the  halo  or  areola.  The 
face  becomes  swollen  and  the  features  are  distorted.  On  the  eleventh 
day  it  is  usually  found  that  pus  oozes  from  the  pustules  which  on  drying- 
forms  the  scab  or  crust.  The  latter  falls  off  sometime  between  the  seven- 
teenth to  twenty-first  days,  leaving  a  red,  glistening  depression  or  pit 
which  soon  changes  into  a  white  cicatrix.  With  maturity  of  the  pustules 
eighth  or  ninth  day)  the  symptoms  observed  at  the  onset  return — 
secondary  fever.  This  fever  of  suppuration  is  the  most  critical  period  of 
the  disease.  In  favorable  cases  the  secondary  fever  abates  after  a  few 
days  and  convalescence  follows.  The  stage  of  suppuration  is  very  prone 
to  be  complicated  by  severe  inflammation  of  the  larynx,  bronchi,  lungs, 
and  serous  membranes.  As  further  complications  or  sequelae  we  may 
mention  stomatitis,  noma,  involvement  of  the  eyes  (phthisis  bulbi),  otitis 
media,  dysentery  and  nephritis. 

Confluent  Form. — This  form  is  characterized  by  extreme  violence 
of  the  constitutional  symptoms  and  by  the  confluence  of  the  eruption 
on  certain  portions  of  the  body,  such  as  the  thigh  and  lower  portion 
of  the  abdomen  and  the  neck. 

Malignant  or  Hemorrhagic  Form. — This  type  of  smallpox  is  charac- 
terized by  malignancy  and  irregularity  of  the  symptoms,  and  coexist- 
ence of  hemorrhages  and  petechias.  In  this  form  are  included  the  so- 
called  black  smallpox  {variola  hemorrhagica  pustulosa)  which  usually 
leads  to  fatal  issue  in  the  suppurative  stage,  and  the  fulminant  type 
of  smallpox  (purpura  variolosa)  which  ends  fatally  within  from  three 
to  four  days. 

In  contrast  to  variola  vera  with  its  dreadful  consequences  stands  vari- 
ola modificata  or  varioloid.  The  latter  form  of  smallpox  is  usually  ob- 
served in  children  rendered  partially  immune  by  previous  vaccination 
or  an  attack  of  smallpox.  Its  course  is  shorter  and  milder  than  that 
of  the  other  forms,  the  eruption  is  slight  and  devoid  of  suppuration, — 
hence  its  freedom  from  secondary  fever  and  severe  complications  and 
sequelae.  The  mortality  in  varioloid  varies  between  8  per  cent  and 
10  per  cent  in  infants  and  about  5  per  cent  in  older  children. 

Smallpox  may  be  confounded,  in  the  initial  stage,  with  meningitis 
and,  in  the  eruptive  stage,  with  varicella  and  morbilli,  especially  morbilli 
hemorrhagici  (q.v.).  Meningitis  can  readily  be  eliminated  after  a  day 
or  two.  The  differential  signs  between  smallpox  and  the  other  exan- 
themata are  outlined  on  p.  398. 

Treatment. — If  the  patient  with  smallpox  is  seen  early,  vaccination 
should  be  performed  at  once ;  it  may  modify  the  attack,*    As  a  prophy- 


*In  mild,  doubtful  cases  vaccination  may  serve  as  a  valuable  aid  in  the  diagnosis,  for  if  suc- 
cessful, it   would   at   once   exclude  the  presence  of  smallpox. 


398 


DISEASES    OF    CHILDREN 


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SPECIFIC    COMMUNICABLE   DISEASES  399 

lactic  measure  it  is  also  advisable  to  vaccinate  all  those  who  come 
and  are  apt  to  come  in  contact  with  the  patient.  Isolation,  disinfection 
and  preparation  of  the  sick-chamber  (the  room  should  be  kept  dark 
by  a  deep-red  shade)  should  be  carefully  carried  out,  in  the  manner 
prescribed  on  p.  69.  The  child  should  be  confined  to  bed,  and  kept 
on  a  light  but  nutritious  diet,  and  liberal  supply  of  stimulants  (wine, 
cognac).  Special  attention  should  be  paid  to  disinfection  of  the 
mouth  and  nasopharynx  (mild  solution  of  potassium  permanganate, 
or  chlorate,  peroxide  of  hydrogen).  In  high  temperature  and  severe 
nervous  phenomena  prolonged  warm  baths  or  cool  packs  act  favorably. 
To  prevent  itching  and  extensive  pitting  we  may  apply  5  per  cent  to 
10  per  cent  of  ichthyol  in  equal  parts  of  zinc  and  sulphur  ointments, 
covered  by  some  unctuous  material  to  exclude  the  air.  It  is  some- 
times necessary  to  tie  the  patient's  hands  to  prevent  scratching;  and 
to  administer  hypnotics  and  anodynes  for  the  relief  of  restlessness  and 
pain.    The  child  should  be  quarantined  for  about  six  weeks. 


IJ     Antipyrinse                 - 

gr.  xxiv 

1.60 

Tr.  Cinchonas  Comp. 

3  iii 

12.00 

Syr.  Aurantii 

'         Si 

30.00 

Aq.  Aurantii 

q.  s.  ad  f  5  ii 

60.00 

M. 

S. — One  teaspoonful  every  four  to  six  hours, 

for  a  child  four  years  old. 

IJ     Mentholis 

gr.v 

0.30 

Bismuthi   Subgallatis 

gr.  X 

0.65 

Zinci  Stearatis 

Sii 

60.00 

M. 

S. — Dusting  powder  to  enhance  desiccation  of 

the  eruption  and  to  relieve 

itching. 

Typhus  Abdominalis 

(Typhoid,  Enteric  Fever) 

Typhoid  fever  is  an  endemic,  epidemic,  and  sporadic  infectious 
disease  due  to  the  bacillus  typhosus  of  Eberth.  It  is  characterized  by 
a  continuous,  typical  fever,  gastrointestinal  catarrh,  and  a  roseolar 
eruption.  With  the  recent  advances  in  bacteriologic  diagnosis  we  are 
now  certain  that  typhoid  occurs  almost  as  frequently  in  children  (even 
fetal  typhoid  is  on  record!)  as  in  adults,  but  owing  to  the  mildness 
of  the  clinical  picture  it  is  frequently  overlooked.  The  younger  the 
child  the  greater  the  deviation  of  the  symptomatology  from  the  usual 
course.  Thus,  the  onset  is  either  more  protracted  (with  symptoms  of 
subacute  gastroenteritis)  than  in  the  adult  or  very  sudden  with  chills 


400 


DISEASES   OF    CHHjDREN 


and  high  fever.  In  the  new])orn  the  symptoms  may  resemble  those 
of  sepsis.  In  older  children  the  initial  stage  {pijro genetic  stage,  first 
week)  resembles  that  of  adults  and  is  marked  by  epistaxis,  frontal  head- 
ache, anorexia,  furred  tongue  (later  dry  and  brown),  restless  sleep,  and 
gradual  rise  of  temperature.  The  action  of  the  bowels  is  not  character- 
istic, and  constipation  may  alternate  with  diarrhea  (sometimes  bloody). 
The  fever  reaches  its  height  with  the  approach  of  the  second  week 
(fastigium),  and  varies  in  mild  cases  between  101°  and  103°  F.  and  in 
severe  cases  between  104°  and  106°  F.,  with  morning  remissions  and 
evening  exacerbations  ("step  curve").  Occasionally  the  tj'pus  inver- 
sus is  observed,  and  not  rarely  the  temperature  is  remarkably  low 
throughout  the  entire  course  of  the  disease.     The  pulse  is  sometimes 


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Fig.  92. — Fever  curve  of  typhoid  fever  in  child  four  years  old. 

very  frequent  (160  to  180)  but  rarely  dicrotic.  The  urine  responds  to 
the  diazo  reaction,  and  contains  traces  of  albumin.  During  this  stage, 
the  second  week,  the  spleen  is  palpable,  but  not  as  distinctly  as  in  adults. 
The  roseolar  eruption  which  usually  appears  about  the  eighth  day  on  the 
abdomen,  chest,  back  and  limbs,  is  rather  scanty  and  not  rarely  entirely 
absent.  The  typical  eruption  consists  of  small,  elevated,  rose-colored 
spots  which  momentarily  disappear  on  pressure.  They  evolve  in  suc- 
cessive crops,  each  crop  lasting  about  three  days,  and  subside  entirely 
after  about  ten  days.  Corresponding  to  the  comparative  mildness  of  the 
intestinal  lesions,  tympanites,  iliac  tenderness  and  gurgling  are  rarely 
marked.    The  same  is  true  of  the  abdominal  pain.    If  it  is  pronounced 


SPECIFIC    COMMUNICABLE   DISEASES  '  "^  '■  '^   '^    '^^  *  401 

we  should  look  for  9,  complicating  cliolpisystitis,  appendicitis,  peritoni- 
tis or  intestinal  perforation.  This  last  complication  is  most  apt  to  oc- 
cur in  the  third  week  of  the  disease,  and  sets  in  either  insidiously  or 
abruptly,  in  the  latter  event  with  a  sharp  fall  and  abrupt  rise  of 
temperature  (often  preceded  by  a  chill  or  vomiting),  meteorism  and 
abdominal  rigidity,  and  subsequent  appearance  of  fluid  in  the  peritoneal 
cavity.  This  process  is  usually  accompanied  by  a  more  or  less  marked 
leucocytosis.  During  the  acme  of  the  fever  there  are  more  or  less 
marked  nervous  phenomena.  Some  patients  are  drowsy  and  apathetic; 
some  are  restless,  shriek,  and  rave ;  some  suffer  from  defective  hearing, 
hyperesthesia,  insomnia,  or  semistupor,  and,  finally,  others  may  be 
dull  during  the  height  of  the  fever  but  otherwise  may  be  playful  during 
the  entire  course  of  the  disease.  Children  almost  never  present  the 
status  typhosus.  As  a  rule,  the  blood  gives  a  positive  Widal  reaction 
{q.v.). 

With  the  beginning  of  the  third  week  {defervesceiit  stage)  there  is  a 
decided  improvement  in  the  general  symptoms.  The  tongue  begins  to 
clear  at  the  edges,  the  appetite  returns  (is  often  voracious),  the  temper- 
ature declines,  as  a  rule,  by  lysis,  and  the  grave  nervous  symptoms  grad- 
ually abate.  The  temperature  sometimes  drops  suddenly  and  remains 
normal  or  even  subnormal.  In  severe  cases,  however,  the  fever  may  con- 
tinue (ambiguous  stage)  and  with  it  all  the  other  symptoms.  Indeed,  in 
older  children  the  intestinal  manifestations  may  become  more  pronounced, 
and  hemorrhage  from  the  bowels,  perforation  and  peritonitis  may  super- 
vene. The  usual  bronchial  catarrh  may  extend  to  the  bronchioles  and 
pulmonary  tissue  and  lead  to  diffuse  bronchopneumonia.  Furthermore, 
improvement  and  recovery  may  be  greatly  delayed  or  entirely  arrested 
by  relapses,  which  are  not  uncommon  between  the  third  and  fifth  weeks, 
or  by  the  following  complications  and  sequelae :  inflammation  of  the  mu- 
cous membrane  of  the  mouth  (occasionally  noma!),  nasopharynx,  and 
larjaix;  parotitis,  otitis,  cutaneous  abscesses,  periostitis,  perispondylitis 
(typhoid  spine) ;  pericarditis,  endocarditis,  purulent  arthritis,  pyemia, 
thrombosis  and  embolism;  paralyses  (usually  neuritis),  chorea,  apha- 
sia (lasts  about  a  week),  dementia,  maniacal  and  melancholy  states. 
The  mental  sequelse  usually  consist  of  merely  temporary  irritability, 
hypersensitiveness,  disposition  to  cry,  caprieiousness  and  surliness.  On 
the  other  hand,  cases  of  permanent  mental  aberration  are  on  record. 
Typhoid  fever  is  sometimes  associated  with  pertussis,  morbilli,  scar- 
latina and  diphtheria,  and  in  cases  with  a  predisposition  it  is  apt  to  be 
followed  by  pulmonary  tuberculosis.  Occasionally,  typhoid  is  followed 
by  a  posttyphoidal  desquamation  of  the  skin,  and  during  and  after 
an  attack  there  is  frequently  a  marked  longitudinal  growth  of  the  bones, 


402  ''     '  DISEASES    OF    CHILDREN 

espqQialJy;  of  the  tubular  bonea; of  the  lower  extremities.  As  a  result  of 
it,  the  skin  over  these  bones  is  sometimes  transversely  torn,  the  tears  be- 
ing indicated  at  first  by  red  lines,  and  later  by  white  scars. 

The  aforementioned  grave  complications  and  sequela;,  are  very  rarely 
observed  in  children.  As  a  rule,  the  prognosis  except  in  very  young 
infants,  is  favorable  (5  to- 10  per  cent  mortality),  and,  even  after  severe 
attacks,  convalescence  is  comparatively  rapid  and  uneventful.  In  young 
children  the  course  of  the  disease  is  usually  very  brief,  between  twelve 
and  fifteen  days ;  in  older  ones  it  is  nearly  the  same  as  in  adults. 

The  morbid  anatomic  condition  in  the  intestines  is  much  milder  than 
in  adults ;  ulcers  are  rare,  and,  if  present,  are  small,  superficial  and  iso- 
lated, hence  they  heal  without  leaving  behind  any  cicatrices  in  the  in- 
testines or  any  tendency  to  cicatricial  contraction. 

In  view  of  these  marked  deviations  from  the  usual  clinical  picture, 
the  diagnosis  of  sporadic  cases  of  typhoid  fever  often  presents  great 
difficulties.  It  is  apt  to  be  mistaken  for  simple  gastroenteritis — febrile 
stage  of  shorter  duration,  spleen,  in  uncomplicated  cases,  not  enlarged, 
diazo  reaction  and  Widal's  blood  test  negative;  influenza  with  pro- 
nounced intestinal  symptoms — febrile  "step"  curve  absent,  nervous  phe- 
nomena less  pronounced,  catarrhal  symptoms  more  marked,  Widal's  test 
negative,  pneumonia — more  sudden  onset,  more  positive  pulmonary 
physical  signs,  Widal's  reaction  negative,  diplococcus  pneumoniae  in  the 
expectoration,  neutrophilic  leucocytosis ;  acute  miliary  tuberculosis — ir- 
regular temperature  with  sweats,  hectic  flush,  often  tuberculous  sputum, 
more  protracted  course,  Widal's  reaction  negative;  tuberculous  meningi- 
tis— lower  temperature ;  slow,  irregular  pulse  and  respiration ;  trough- 
shaped  abdomen ;  malaria — usually  intermittent  or  recurrent  fever,  ma- 
laria Plasmodium  in  the  blood,  influenced  by  quinine ;  septic  endocarditis 
— pronounced  heart  symptoms,  chills  with  septic  temperature,  absence  of 
Widal's  reaction;  tick  or  Rocky  Mountain  spotted  fever — endemic  of 
this  region,  characterized  by  a  continuous,  moderately  high  fever,  severe 
muscular  and  arthritic  pains,  profuse  petechial  or  purpural  skin  erup- 
tion appearing  first  on  the  ankles,  wrists  and  forehead.  Widal  reaction 
is  negative;  typhus,  spotted  fever — general  malaise,  irregular  pain 
throughout  body,  continuous  fever,  ending  by  crisis  on  the  fourteenth 
day.  Macular,  petechial  rash  usually  on  the  third  to  sixth  day  upon 
body  and  extremities.  Weil-Felix's  reaction  is  positive.  Widal's  re- 
action is  negative.  Occasionally  typhoid  begins  with  pain  in  the  occiput, 
neck  and  back,  opisthotonos,  and  other  grave  nervous  phenomena,  pre- 
senting the  clinical  picture  of  acute  meningitis.  The  diagnosis  in  such 
cases  is  often  almost  impossible  in  the  first  few  days  of  the  disease.  In 
doubtful  cases  the  bacteriologic  examination  of  the  cerebrospinal  fluid 


SPECIFIC    COMMUNICABLE   DISEASES  403 

for  the  diplococcus  intracelliilaris,  and  of  the  stools  and  urine  for  the 
bacillus  t.yphosns  often  proves  decisive. 

Treatment. — As  the  eontagium  of  typhoid  fever  resides  principally 
in  the  gastrointestinal  contents,  it  is  imperative  to  disinfect  the  stools 
and  vomitus  thoroughly,  as  well  as  the  linen  and  other  articles  in  use 
that  have  been  soiled  by  the  discharges.  Furthermore,  by  taking  the 
precaution  of  boiling  the  drinking  water  or  milk,  excluding  mosquitoes 
and  flies  from  the  sick-room,  and  by  avoiding  dissemination  of  the 
source  of  infection  through  soiled  bath  tubs,  hands,  etc.,  the  disease 
may  be  limited  to  a  single  patient  notwithstanding  the  intercommuni- 
cation between  the  patient  and  other  members  of  the  family.  Strict 
isolation,   therefore,   is  not   essential.     Prophylactic  immunization ! 

Typhoid  fever  is  a  self -limited  disease  and  not  controllable  by  any 
specific  measures.  The  treatment,  therefore,  should  be  symptomatic, 
principally  hygienic  and  dietetic.  Cleanliness  of  the  mouth  and  naso- 
pharynx, cool  sponging  of  the  body,  with  water  or  alcohol  or  vinegar, 
or  if  the  temperature  is  high,  cool  packs  or  full  baths,  at  a  tempera- 
ture of  from  80°  to  90°  F.,  and  an  ice  bag  to  the  head,  usually  suffice 
to  make  the  patient  fairly  comfortable.  During  the  first  few  days 
we  may  administer  small  doses  of  calomel  and  bismuth,  and  later 
dilute  hydrochloric  acid,  pineapple  juice  and  some  good  wine  or  cog- 
nac. Hexamethylenamine  (2  to  5  grains)  is  useful  during  the  entire 
course  of  the  disease.  In  intestinal  hemorrhage,  an  ice  coil  to  the  ab- 
domen and  opium  suppository  (^4o  grain  for  every  year  of  the  child's 
age)  will  be  found  very  efficient.  When  the  hemorrhage  is  excessive, 
transfusion  and  surgical  treatment  should  be  instituted  without  delay. 
Rest  in  bed  should  be  enjoined  for  at  least  two  weeks  after  deferves- 
cence. The  diet  should  be  fluid  (milk  with  tea,  amply  sweetened  with 
milk  sugar,  or  malt  sugar,  soups,  light  gruels,  chicken  broth,  zoolak, 
egg  with  sherry  wine,  ice  cream)  during  the  acute  course  of  the  dis- 
ease, and  semisolid  thereafter,  care  being  taken  not  to  overfeed. 
Transition  to  a  more  solid  diet  should  be  very  gradual.  Relapses  call 
for  the  same  mode  of  treatment  as  the  original  attack.  During  con- 
valescence the  different  bitter  tonics  and  iron  are  very  desirable,  and 
a  sojourn  at  the  seashore  often  works  wonders. 

Complications  should  be  carefully  guarded  against  and  immediately 
treated  according  to  indications.  Frequent  change  of  position  of  the 
patient  is  usually  effective  to  prevent  serious  pulmonary  complications 
as  well  as  decubitus.  The  skin  should  be  hardened  by  alcohol,  alum 
water,  etc.,  and  as  much  as  possible  protected  by  air  cushions.  The 
slightest  abrasion  of  the  skin  should  at  once  be  treated  by  antiseptic 


404  DISEASES   OP   CHILDREN 

dressings  (2  per  cent  solution  of  aluminum  acetieotartrate).  It  is 
claimed  that  the  external  application  of  castor  oil  prevents  and  cures 
decubitus.  Insomnia  and  excessive  restlessness  sometimes  require 
hypnotics. 

Typhus  Exanthematicus 

Typhus  Fever,  Spotted  Fever,  Ship  Fever,  Jail  Fever,  Camp  Fever, 

Tabardillo   (Mexico) 

Typhus  fever  is  an  acute  infectious,  endemic,  epidemic  and  spo- 
radic disease  of  doubtful  origin  (the  B.  typhi  exanthematici,  Plotz,  is  as 
yet  not  generally  accepted  as  the  true  cause),  transmitted  through 
the  body  louse  and  characterized  by  a  discrete,  maculated,  petechial 
rash,  and  moderate  fever,  terminating  by  crisis  in  from  ten  to  fourteen 
days.  The  prodromic  stage  lasts  from  a  few  hours  to  several  days  and 
is  followed  by  severe  headache,  usually  frontal,  and  pain  in  the  back 
and  extremities.  The  eruption  generally  appears  on  the  fourth  or  fifth 
day,  is  rose  colored  or  hemorrhagic,  and  scattered  all  over  the  body 
and  more  especially  over  the  trunk  and  limbs.  The  spots  do  not  dis- 
appear on  pressure.  The  patients  usually  manifest  a  tendency  to  very 
rapid  breathing,  in  the  absence  of  other  lung  symptoms.  In  young 
children  bronchopneumonia  is  not  uncommon.  The  blood  shows  a 
marked  leucocytosis.  During  the  absence  of  an  epidemic  the  diagnosis 
is  often  difficult  until  the  termination  of  the  disease  (the  sudden  drop 
of  temperature !)  and  may  readily  be  mistaken  for  typhoid  fever 
(Widal  positive,  see  p.  86)  and  relapsing  fever  (recurrence  of  fever, 
spirillum  in  the  blood).  Positive  Weil-Felix  reaction  {q.v.)  is  decisive 
of  the  diagnosis  of  typhus  exanthematicus. 

The  treatment  is  chiefly  prophylactic  (destruction  of  lice,  fleas,  etc.) 
and  hygienic.    Individual  symptoms  are  treated  according  to  indications. 

Typhus  Recurrens 

(Febris  Recurrens,  Relapsing  Fever,  Spirochetosis) 

This  affection  is  quite  common  in  Europe,  and  in  some  African  states, 
but  is  very  rarely  observed  in  the  United  States.  It  is  due  to  a  spiro- 
chete, varying  in  type  in  different  countries,  which  was  first  described 
by  Obermeier  in  1873.  Other  types  of  the  spirochete  have  since  been 
demonstrated  by  Button,  Carter  and  Novy.  The  disease  is  conveyed 
to  men  by  ticks,  bedbugs,  fleas,  lice  and  flies.  It  is  characterized  by  two 
or  more  febrile  paroxysms  of  six  days'  duration  succeeded  by  afebrile 
intervals  of  equal  length.    The  temperature  ranges  between  104°  and 


SPECIFIC    COMxMUNICABLE   DISEASES  405 

106°  F.  and  comes  down  l)y  lysis  witli  profuse  sweating  and  sound 
sleep.  During  the  afebrile  stages  the  patient  seems  in  fairly  good 
health.  There  is  usually  an  enlargement  of  the  liver  and  spleen  and 
in  severe  cases  profuse  diari-hea,  dysentery  and  hematemesis  are  ob- 
served. The  spirochetes  are  circulating  in  the  blood  during  the  height 
of  the  fever. 

Treatment. — Prophylaxis  is  readily  accomplished  by  extermination 
of  the  purveyors  of  the  disease.  The  active  treatment  consists  of  intra- 
venous administration  of  neosalvarsan  in  doses  from  0.1  to  0.4,  to  be  re- 
peated every  three  or  four  days  until  the  spirochete  has  been  eliminated 
from  the  blood.    Other  symptoms  are  treated  according  to  indications. 

Glandular  Fever 

(Pfeiffer) 

Glandular  fever  is  an  infectious  disease  which  sometimes  occurs  in 
epidemics,  most  frequently  among  children  from  two  to  eight  years  of 
age.  The  portal  of  entry  of  the  infection  is  the  rhinopharynx.  Simul- 
taneously with  a  rapid  rise  in  temperature  (102°  to  104°  F.)  there  ap- 
pear more  or  less  painful  swellings  of  the  submaxillary  and  cervical 
glands — which  usually  interfere  with  the  movements  of  the  head — 
redness  of  the  throat,  headache,  sometimes  vomiting  and  diarrhea,  and 
occasionally  enlargement  of  the  spleen  and  liver. 

The  fever  usually  disappears  soon,  sometimes  within  twenty-four 
hours  ("one  day  fever"),  but  the  glandular  swelling  persists  for  sev- 
eral weeks  and  exceptionally  spreads  to  other  lymph  nodes  of  the 
body,  e.g.,  bronchial  (cough),  esophageal  (dysphagia)  and  retroperi- 
toneal (pain  in  the  abdomen,  especially  on  pressure).  Occasionally 
this  disease  is  complicated  by  nephritis,  but  the  prognosis  as  a  whole 
is  good. 

In  the  early  stages  glandular  fever  may  be  mistaken  for  tonsillitis 
or  parotitis. 

The  treatment  is  symptomatic,  calomel  and  the  salicylates  internally 
and  a  mild  iodine  ointment  externally,  ordinarily  serving  the  purpose 
of  relieving  the  pain,  fever  and  swelling.  Tonics  and  change  of  air  in 
protracted  cases. 

Malaria 

(Febris  Intermittens,  Febris  Remittens,  Estivo- Autumnal) 

Malaria  is  endemic  in  the  greater  portion  of  the  inhabited  world, 
and  is  most  prevalent  in  swampy  tropical  regions.  No  age  is  exempt 
from  this  disease.     The  exciting  cause  of  malaria  is  the  hematozoon 


406  DISEASES   OP    CHILDREN 

of  Laveran  conveyed  to  the  human  body  principally  by  the  bite  of 
the  Anopheles  mosquito  which  has  previously  sucked  the  blood  of  a 
malarial  patient  and  has  acted  as  an  intermediate  host  for  the  malarial 
parasite.  The  hematozoon  enters  the  blood  corpuscles  and,  after  un- 
dergoing the  different  stages  of  development,  the  blood  current — at 
this  time  giving  rise  to  the  characteristic  chill  or  paroxysm.  Vary- 
ing with  the  period  of  maturity  and  the  species  of  the  Plasmodium, 
the  febrile  attack  may  occur  every  day  (quotidian)  ;  every  two  days, 
going  on  the  third  (tertian)  ;  every  three  days,  going  on  the  fourth 
(quartan)  day;  or  may  be  more  or  less  continuous  with  daily  remis- 
sions (remittent  or  estivo-autumnal  fever).  Furthermore,  several  types 
of  Plasmodia  or  several  generations  of  the  same  parasite  may  circu- 
late in  the  blood,  and,  by  varying  in  the  period  of  their  maturity, 
may  give  rise  to  double  tertian  or  quartan  paroxysms  daily  or  every 
other  day  at  different  hours. 

Intermittent  Fever 

This  form  of  malaria  is  characterized  by  the  occurrence,  at  regular 
intervals,  of  paroxysms  divided  into  four  stages — premonitory,  chill, 
fever,  and  the  sweat.  During  the  premonitory  stage  the  patient  com- 
plains of  headache,  lassitude,  and  nausea;  he  vomits,  yawns,  is  irri- 
table and  drowsy.  Suddenly  he  is  seized  with  a  feeling  of  cold — the 
chill.  The  features  become  pinched,  the  lips  blue,  the  skin  cool  and 
rough  (cutis  anserina)  ;  he  shivers  and  shakes,  and  his  teeth  chatter 
while  the  thermometer  in  the  axilla  or  rectum  shows  a  decided  rise 
of  temperature.  These  phenomena  may  continue  for  from  a  few 
minutes  to  an  hour  or  longer  and  are  then  gradually  replaced  by  those 
of  the  hot  stage,  i.  e.,  hyperpyrexia,  flushed  face,  headache,  full  pulse, 
intense  thirst,  scanty  urine,  sometimes  nausea,  vomiting  and  severe 
nervous  manifestations.  The  hot  stage  lasts  from  three  to  six  hours 
or  longer,  and  subsides  gradually,  being  succeeded  by  more  or  less 
marked  sweating,  defervescence  and  rapid  abatement  of  the  other 
symptoms.  The  duration  of  the  entire  paroxysm  is  from  six  to  twelve 
hours,  after  which  time  the  patient  is  apparently  well — until  the  return 
of  a  new  attack  which  as  already  mentioned  may  occur  every  day,  every 
two  days  or  three  days. 

This  description  corresponds  with  the  symptomatology  of  typical 
intermittent  fever,  uninfluenced  by  medication,  as  it  occurs  in  chil- 
dren over  ten  years  of  age.  It  is  thus  identical  with  that  in  adults. 
In  younger  children  the  course  of  the  paroxysms  presents  numerous 
deviations.    The  prodromic  and  cold  stages  may  be  absent  or  of  very 


PLATE  IX 
Life-Cycle  of  Plasmodium  Vivax 

(After  Grassi  and  Schaudinn  ) 
The  human  cycle  is  above  the  transverse  line,  some  rearranged  by  Kissalt  and 
Hartmann.  The  cycle  in  the  mosquito  is  beneath.  1  to  7,  Schizogony;  1,  sporozoite; 
2,  entrance  of  sporozoite;  3  and  4,  growth  of  the  schizont;  5  and  6,  nuclear  division 
of  the  schizont;  7,  formation  of  the  merozoites;  8,  merozoites;  9a  to  12a,  growth  of 
the  maerogametocyte ;  9b  to  12V),  growth  of  microgametocyte ;  13c  to  17c,  partheno- 
genesis of  the  maerogametocyte;  13a  and  14a,  maturation  of  macrogamete;  13b  and 
14b,  growth  of  the  microgamete ;  15b,  microgamete;  16,  fructification;  17,  Ookinete; 
18  to  20,  entrance  of  the  Ookinete  into  the  stomach  wall  of  the  mosquito;  20  to  25, 
sporogony;  22  and  23,  nuclear  multiplication  in  the  sporont;  24  and  25,  formation 
of  the  sporozoites;  26,  passage  of  the  sporozoites  to  the  salivary  gland;  27,  salivary 
gland  of  the  mosquito  with  sporozoites  (Magn.  1  to  17c,  1200  to  1;  18  to  27c,  600 
to  1.)     Park:  Fatlwgenic  Bacteria  and  Protozoa. 


SPECIFIC    COMMUNICABLE   DISEASES  407 

brief  duration.  The  chill  may  be  replaced  by  grave  nervous  mani- 
festations, such  as  convulsions,  or  be  indicated  only  by  cyanosis  of  the 
lips  and  the  tips  of  the  fingers  and  toes.  Sweating  is  slight  or  absent, 
or  may  be  well  marked  and  continue  until  the  subsequent  paroxysm 
of  fever.  Young  children  are  rarely  entirely  free  from  discomfort  during 
the  intermittent  stage.  As  a  rule,  they  are  exhausted,  restless,  have  no 
appetite,  etc.  With  repeated  attacks  of  the  fever  there  is  marked 
swelling  of  the  spleen  and  great  diminution  in  the  number  of  red 
blood  cells. 

In  view  of  the  aforementioned  deviations  from  the  typical  course 
of  the  paroxysms,  the  diagnosis  of  intermittent  fever  in  young  children 
often  presents  great  difficulties.  It  is  apt  to  be  mistaken  for  tuber- 
culous (meningitis,  lymphangitis,  peritonitis,  etc.)  and  pyemic  (em- 
pyema, pyelitis,  ulcerative  endocarditis,  otitis,  etc.)  processes,  typhoid 
and  influenza.  A  correct  diagnosis,  however,  can  usually  be  arrived 
at  by  exclusion,  always  bearing  in  mind  the  facts  that  in  malaria  the 
Plasmodium  malaria  or  secondary  pigmentation  of  the  blood  cells 
is  invariably  present  in  the  blood  and  that  the  course  of  the  disease 
is  greatly  modified  by  full  doses  of  quinine. 

Remittent  (Estivo-autumnal)  Fever 

This  type  of  malarial  fever  is  usually  observed  in  the  temperate 
zones,  principally  in  the  autumn.  In  institutions  where  large  num- 
bers of  children  are  congregated,  it  may  occur  in  epidemic  form  and 
lead  to  grave  diagnostic  errors.  It  usually  sets  in  suddenly  with  ma- 
laise and  chilliness,  followed  by  fever  with  exacerbations  and  remis- 
sions, the  temperature  during  the  latter,  however,  remaining  con- 
stantly above  normal.  The  other  symptoms  are  very  indefinite.  As 
in  all  febrile  diseases,  anorexia,  nausea,  sometimes  vomiting,  head- 
ache, drowsiness  and  lassitude  predominate.  In  some  cases  gastro- 
intestinal symptoms  prevail,  in  others  respiratory.  But  the  cardinal 
manifestations  of  the  affection  are  the  continued  fever  of  from  one  to 
three  weeks'  duration,  with  irregular  remissions,  palpable  spleen,  and 
the  Plasmodium  malaria}  in  the  blood.  Bearing  these  clinical  symp- 
toms in  mind  and  those  of  the  diseases  suspected,  there  ought  to  be 
no  difficulty  in  dififerentiating  remittent  fever  from  typhoid  fever  or 
protracted  influenza — with  both  of  which  diseases  it  is  most  apt  to 
be  confounded.  The  quinine  test  is  not  reliable  in  the  remittent  form 
of  malaria  as  the  fever  often  resists  medication. 

The  prognosis  of  remittent  fever  is  favorable,  except  for  the  ten- 
dency to  recurrences  at  shorter  or  longer  intervals  and  of  ultimately 
becoming  chronic. 


408  DISEASES    OP    CHILDREN 

Chronic  Malarial  Cachexia 

The  diagnosis  of  this  condition  is  often  very  difficult,  since  its  prin- 
cipal symptoms — anemia,  debility,  enlarged  spleen  and  liver — are 
also  pathognomonic  of  severe  rachitis,  pseudoleukemia,  and  similar 
wasting  diseases.  Corroborative  data  may  be  obtained  from  a  history 
of  previous  attacks  of  either  intermittent  or  remittent  fever  or  the 
occurrence  of  periodical  headache,  neuralgia,  dysentery  or  hematuria. 
One  should  be  very  cautious,  however,  in  making  a  hasty  diagnosis 
of  "malaria"  unless  there  be  ample  reason  for  exclusion  of  the  other 
affections  and  the  therapeutic  quinine  test  prove  positive. 

Chronic  malarial  cachexia  per  se  is  not  dangerous  to  life,  but  is  apt 
to  prove  so  from  its  concomitant  symptoms,  such  as  profound  anemia 
and  amyloid  degeneration  of  the  viscera. 

Treatment. — As  malarial  fever  is  ordinarily  contracted  through  the 
bites  of  mosquitoes,  to  prevent  malarial  disease,  we  must  either  de- 
stroy the  mosquitoes  or  avoid  their  bites.  An  effort  should  be  made 
also  to  isolate,  by  mosquito  netting,  all  cases  of  acute  malarial  disease, 
in  order  to  deprive  the  mosquitoes  of  the  infective  material.  Another 
very  important  measure  is  to  prevent  the  breeding  of  mosquitoes. 
Mosquitoes  lay  their  eggs  in  water  barrels,  pans,  tin  cans,  pots,  kettles, 
wells,  springs,  rain  pools,  cess  pools,  drainage  taps,  ponds — in  short, 
wherever  stagnant  water  is  found.  We  have  to  see  to  it  that  all 
water  receptacles  are  closely  covered  with  thin  wire  gauze,  and  that 
where  drainage  cannot  be  carried  out,  the  surface  of  ponds,  etc.,  are 
covered  with  a  film  of  kerosene  oil.  One  ounce  of  oil  to  15  square 
feet  of  water  will  usually  suffice.  The  oil  must  be  renewed  about  once 
a  week  during  the  mosquito  season.  A  solution  containing  1  pound 
of  sulphate  of  copper  and  1  pound  of  unslaked  lime  in  10  gallons 
of  water  will  kill  the  mosquito  larvas  when  added  in  proportion  of  1  of 
the  solution  to  50  of  the  infected  water. 

White  people  settling  in  malarial  tropical  regions  should  not  plant 
their  houses  near  native  settlements. 

Where  the  aforementioned  prophylactic  measures  cannot  be  prop- 
erly enforced,  resort  should  be  had  to  the  routine  administration  of 
quinine  during  the  mosquito  season.  Whether  as  a  prophylactic  or 
curative  measure,  quinine  is  the  specific  destructive  agent  of  the 
malarial  parasites.  To  obtain  prompt  results  it  should  be  given  in  full 
doses.  Children  tolerate  relatively  much  larger  quantities  of  quinine 
than  adults.  An  infant  of  two  years  requires  about  15  or  20  grains 
a  day  until  the  attack  is  controlled,  and  smaller  doses  after.  For  chil- 
dren unable  to  take  quinine  in  capsules,  I  prefer  the  newer  "tasteless" 


SPECIFIC    COMMUNICABLE   DISEASES  409 

quinine  preparations,  such  as  quinine  ethyl  carbonate,  diquinine  car- 
bonic ester,  etc.,  or  quinine  tannate,  or  I  administer  the  ordinary  bit- 
ter quinine  per  rectum  (10  grains  of  quinine  subsulphate  in  4  drams  of 
water  by  means  of  colon  tube).  In  cases  of  marked  gastric  irritability 
or  in  those  very  grave  in  nature  or  protracted  in  course,  quinine  may 
be  employed  in  5  grain  doses  hypodermically.  For  this  purpose,  bi- 
muriate  of  quinine  and  urea,  the  hydrochlorosulphate,  the  hydrobro- 
mate,  or  the  bisulphate  may  be  used.  Ugly  sloughing  which  is  apt 
to  follow  at  the  site  of  the  injection  may  be  prevented  by  cleanliness 
of  the  needle  and  skin,  and  by  throwing  the  solution  deeply  into  the 
subcutaneous  tissues  and  sealing  the  point  of  puncture  with  adhesive 
plaster. 

In  protracted  cases  iron  and  arsenic  (Fowler's  solution)  will  be 
found  useful  additions  to  the  quinine.  When  there  is  a  great  tendency 
to  recurrences  of  the  malaria,  permanent  residence  in  dry  mountainous 
regions  will  sometimes  remain  the  only  curative  measure  at  our  com- 
mand. 

IJ     Quinine  Ethyl  Carbonate,  or 

Diquinine  Carbonic  Ester  3  ss  2.00 

Syr.  simplicis  5  ii  60.00 

M. 
S. — One   teaspoonful  every  two  to   four  hours,   for 
a  child  three  years  old. 

IJ     Quininse   Mur.  gr.  xv  1.00 

Aeetanilidi  gr.  vi  0.40 

Podophyllini  gr.  %  0.008 

Ext.  Nucis  Vomicae  gr.  %  0.016 
M.  ft.  caps.  no.  xii. 
S. — Two  capsules  eveiy  three  hours,  for  a  child  six 

years  old. 

IJ     Acidi  Arsenosi 

Quininas  Mur. 

Ferri  Sulph.   Exs. 

Pulv.  Ehei 

M.  ft.  caps.  no.  xx. 
S. — Two  capsules  every  six  hours,  for  a  child  ten 
years  old   (in  chronic  malaria). 

Ij!;     Elixir  Ferri  Pyrophosphatis,  Quininae 

et   Strychnine    (N.F.)  g  i  ss  45.0 

Syr.  Aurantii  q.  s.  g  iii  90.0 

M. 
S- — One  teaspoonful  three  times  a  day,  for  a  child 
four  years  old   (in  convalescence). 


gr-  VlO 

0.006 

3ss 

2.00 

gr.x 

0.66 

gr.  V 

0  33 

410  DISEASES   OP    CHIILDREN 

Treatment  should  not  be  discontinued  until  the  blood  has  become 
free  from  plasmodia  or  pigment  and  the  spleen  has  assumed  its  normal 
size. 

Dengue 
(Breakbone  Fever.     Seven-Days-Fever) 

This  specific  affection  is  transmitted  by  bites  of  mosquitoes,  the  Culex 
fatigmis  and  Stegomyia  fasciata.  While  most  common  in  the  tropics,  it 
is  not  rarely  observed  in  Texas.  It  is  characterized  by  two  febrile 
paroxysms  of  about  three  days'  duration  with  an  intermission  of  a  day 
or  two.  The  drop  of  temperature  is  accompanied  by  profuse  sweating. 
With  the  second  rise  of  temperature  a  roseolar  or  scarlet-like  eruption 
makes  its  appearance.  The  disease  is  associated  with  a  marked  leuco- 
penia,  severe  pain  in  the  head  (eyeballs),  back  and  joints,  and  in  young 
children,  delirium  and  convulsions — the  latter  probably  the  result  of 
hyperpyrexia  (104°  to  106°  F.).  The  second  or  third  attack  is  milder 
than  the  first  one.  The  disease  is  benign  in  character  and  usually  re- 
sponds promptly  to  the  administration  of  salicylates  and  quinine. 

In  a  recent  paper  on  dengue  Ch.  F.  Craig*  reaffirms  his  views  on 
the  similarity  of  dengue  and  yellow  fever,  both  clinically  and  etiologi- 
cally  and  speaks  strongly  in  favor  of  the  spirochetal  nature  of  dengue. 
Clinically,  both  diseases  have  a  sudden  onset,  run  a  comparatively 
rapid  course,  and  terminate  by  crisis  rather  than  by  lysis. 

In  both  diseases  the  cause  is  present  in  the  blood,  but  only  during 
certain  periods;  in  both,  the  injection  of  unfiltered  blood  from  patients 
suffering  from  the  disease  results  positively,  the  incubation  period  in 
yellow  fever  being  usually  three  and  a  half  days,  while  in  his  experi- 
ments, the  incubation  period  in  dengue  averaged  three  days,  fourteen 
hours;  in  both,  the  injection  of  filtered  blood  produces  the  disease, 
thus  proving  that  both  are  due  to  a  filtrable  virus ;  in  both,  the  transmit- 
ting agent  is  a  mosquito ;  and  both,  finally,  have  proved  to  be  non- 
contagious. 

Rocky  Mountain  Fever 

(Tick  Fever,  Spotted  Fever) 

This  disease  is  endemic  in  the  valleys  of  the  Eocky  Mountains  in 
Idaho  and  Montana.  It  has  also  been  found  in  the  valleys  of  Nevada 
and  Wyoming.  It  occurs  in  the  spring  months  and  while  the  cause  of 
the  affection  is  still  unknown,  it  has  been  definitely  established,  espe- 
cially by  Ricket  and  King  that  it  is  transmitted  by  infected  ticks,  the 
Dermacentor  occidentalis.     The  disease  is  characterized  by  a  continu- 


•Jour.  Am.  Med.  Assn.,  Oct.  30,  1920. 


SPECIFIC    COMMUNICAHLE   DISEASES  411 

ous  moderate  fever,  which  falls  by  lysis,  severe  chills,  arthritic  and 
muscular  pain,  and  a  profuse  macular,  or  petechial  rash,  which  appears 
(from  the  second  to  the  fifth  day)  first  upon  the  ankles,  wrists  and 
forehead  but  soon  spreads  over  the  entire  body.  In  severe  cases  there 
may  be  delirium,  tachycardia,  out  of  proportion  to  the  temperature, 
albuminuria  and  casts  and  jaundice. 

Treatment. — Protection  against  the  bites  of  the  ticks,  particularly  by 
protecting  the  hands  and  feet.     The  active  treatment  is  symptomatic. 

Pestis  Americana 

(Yellow  Fever.    The  Yellow  Jack) 

While  the  specific  microbe  of  this  acute  infectious  fever  is  still  un- 
discovered,* it  is  definitely  settled — thanks  principally  to  the  investi- 
gations of  Ch.  Finley,  Reed,  Carroll,  Agramonte  and  Lazear — that 
yellow  fever  is  spread  by  the  bite  of  the  Stegomyia,  calopus  mosquito. 

Pathology. — The  liver  is  the  chief  seat  of  the  pathologic  alterations. 
The  liver  cells  swell  and  degenerate  and  by  pressure  upon  the  capillaries 
obstruct  the  fiow  of  bile  and  thus  give  rise  to  the  hepatogenous  jaundice. 
The  degenerative  process  proceeds  also  in  the  interlobular  capillaries, 
interfering  with  the  portal  circulation  and  causing  congestion  of  the 
gastrointestinal  tract.  On  postmortem  examination  the  stomach  and 
intestines  are  often  found  to  contain  large  quantities  of  blood.  Puncti- 
form  hemorrhages  are  observed  also  in  the  other  organs  of  the  body. 

Symptomatology. — After  an  incubation  period  of  from  2  to  6  days, 
the  attack  usually  sets  in  with  vomiting,  severe  abdominal  and  spinal 
pain,  high  fever  (about  104°  F.)  not  rarely  convulsions,  and  albuminuria 
(usually  the  second  day).  This  attack  may  last  from  two  to  four  days 
and  is  followed  by  a  24  hours'  remission  accompanied  by  sweating,  when 
the  second  paroxysm  of  fever  develops  with  marked  jaundice,  hemor- 
rhage from  the  stomach  (black  vomit),  slow  pulse  and  general  prostra- 
tion. This  paroxysm  in  favorable  cases  usually  lasts  from  two  to  three 
days;  the  patient  passes  into  a  sound  sleep  and  is  then  well  on  the  road 
to  convalescence.  In  unfavorable  cases  the  temperature  continues  to 
rise,  the  hemorrhagic  vomiting  persists,  and  there  develop  in  addition, 
clammy  sweats,  complete  anuria,  delirium,  convulsions  and  coma.  In 
the  United  States  the  mortality  ranges  between  20  and  25  per  cent. 

Mild  cases  may  be  mistaken  for  dengue  and  malarial  fever — in  neither 
of  these  affections,  however,  do  we  find  albuminuria  and  marked  jaundice. 
Furthermore,  malaria  presents  the  Plasmodium  in  the  blood.  (See  "Den- 
gue.") 


*Noguchi  claims  that  it  is  a  spirochete,   the  Leptospira  icteroides.      (Jour.   Am,   Med.   Assn., 
Jan.  8,  1921.) 


412  DISEASES    OF    CHILDREN 

Treatment. — Destruction  of  mosquitoes  at  their  source ;  screening  of 
the  patient,  and  fumigation  of  the  sick  room  with  sulphur  or  formalde- 
hyde.   Prophylactic  inoculation  is  recommended  by  Noguchi  and  Pazeja. 

The  active  treatment  is  symptomatic.  With  the  claim  of  a  spirochete 
being  the  cause  of  yellow  fever,  neosalvarsan  would  seem  to  me  to  be  the 
remedy  worth  trying.  Plenty  of  alkaline  waters,  warm  baths,  liquid 
diet,  cardiac  stimulants,  and  sedatives,  if  the  pain  is  very  severe. 

Ileocolitis  Epidemica 

(Dysentery) 

This  form  of  dysentery  is  entirely  distinct  from  hemorrhagic  enteritis 
or  proctitis  spoken  of  in  connection  with  gastroenteritis  on  page  257. 
It  is  an  infectious  epidemic,  and  sometimes  sporadic  disease,  caused  by 
the  dysentery  bacilli  described  by  Shiga,  Kruse  and  Flexner.  Amebic 
dysentery  which  is  seen  here  sporadically  is  endemic  in  the  tropics.  The 
lesion  is  localized  principally  in  the  sigmoid  flexure  and  rectum,  or  also 
in  the  entire  colon  up  to  the  ileocecal  valve  or  even  the  lower  portion  of 
the  ileum,  and  varies  from  a  simple  inflammation  of  the  mucosa  to 
a  croupous,  diphtheritic  inflammation,  with  a  fibrinous  exudate  or  a 
membranous  deposit,  ulcer  formation,  and  necrosis  (gangrene).  Dysen- 
tery is  most  common  during  August  and  September  and  late  in  autumn. 
It  most  frequently  affects  young  children  who  are  on  a  mixed  diet. 

In  the  majority  of  instances  dysentery  begins  with  simple  diarrhea, 
without  constitutional  symptoms,  and  after  from  twenty-four  to  forty- 
eight  hours  is  followed  by  the  characteristic  symptoms  later  to  be  spoken 
of.  In  some  cases  the  onset  is  sudden  with  high  fever  and,  in  small 
children,  with  convulsions.  Once  the  affection  is  established  the  symp- 
tomatology is  quite  pathognomonic :  colic,  tenesmus,  and  bloody  stools. 
The  colic  precedes  and  accompanies  defecation  and  is  followed  by  severe 
and  prolonged  tenesmus.  The  bowel  movements  vary  between  ten  and 
thirty  or  more  in  twenty-four  hours,  and  the  dejecta  consist  either  of 
pure  blood  or  of  blood  and  dirty  ragged  shreds  of  tissue  and  fecal  masses. 
The  abdomen  is  most  frequently  sunken,  permitting  palpation  of  the 
contracted  colon.  The  tongue  is  dry  and  heavily  coated,  the  lips  are 
cracked  and  covered  with  sordes,  the  appetite  is  lost,  and  the  child 
suffers  from  intense  thirst,  and  occasionally  from  nausea  and  vomiting. 
As  a  rule,  the  temperature  is  raised  (intermittent),  but  it  may  be  normal 
or  subnormal.  After  a  few  days  the  patient  becomes  greatly  emaciated 
and  prostrated,  very  anemic,  and  the  expression  of  the  face  denotes 
great  suffering.  Quite  a  number  of  children  succumb  during  this  stage 
of  the  disease  (fulminating  type)  ;  others  again  continue  to  battle  for  life 
and  after  a  course  of  from  seven  to  ten  days  begin  to  improve,  the  stools 


SPECIFIC    COMMUNICAnLE   DISEASES  413 

becoming  less  bloody  and  more  feculent  in  character,  the  anorexia  less 
marked,  and  the  general  condition  much  better.  Relapses  are  not  rare, 
and  when  they  occur,  there  is  a  great  tendency  toward  the  transition  of 
the  acute  into  a  chronic  process,  with  a  very  tedious  convalescence,  or 
death  from  exhaustion. 

An  attack  of  dysentery  may  be  complicated  by  perforation  peritonitis, 
abscess  of  the  liver,  fissura  or  prolapsus  ani,  pulmonary  affections,  noma, 
parotitis  suppurativa,  etc.,  and  may  be  followed  by  intestinal  cicatrices 
and  stenosis,  paralysis  of  the  sphincters,  paresis  of  the  extremities,  and 
marasmus. 

The  very  protracted  cases  of  dysentery  are  usually  found  to  be  due  to 
the  ameba  coli  (entameba  histolytica  dysenteriae).  The  differentiation 
between  this  form  of  dysentery,  that  due  to  Shiga's  bacillus,  and  catar- 
rhal enteritis  is  important  from  the  therapeutic  point  of  view  and  can 
readily  be  made  by  a  bacteriologic  and  microscopic  examination  of  the 
dejecta.  Furthermore,  it  is  well  to  remember  that  foreign  bodies  in  the 
lower  bowel  may  give  rise  to  a  group  of  symptoms  similar  to  those  of 
dysentery;  and  that  an  inflamed  prolapsed  rectum,  intussusception,  an 
ulcerated  rectal  growth  or  hemorrhoids  with  coincident  enteritis  are 
very  apt  to  mislead  in  the  diagnosis.  Careful  examination  (inspection 
and  palpation)  of  the  rectum  disposes  of  these  difficulties. 

Treatment. — Similar  to  a  patient  with  typhoid,  patients  suffering 
from  dysentery  need  not  be  strictly  isolated.  The  dejecta  and  every- 
thing coming  in  contact  with  them,  however,  should  be  thoroughly  disin- 
fected. During  an  epidemic  the  drinking  water,  fruit  and  vegetables 
should  be  boiled,  and  all  modes  of  exposure  to  infection  (mosquitoes, 
flies!)  avoided. 

Acute  dysentery  calls  for  perfect  rest  in  bed,  an  opiate  (preferably 
hypodermically  or  per  rectum)   for  the  relief  of  pain,  and  light  as- 
tringent diet  (tea  and  toast  without  sugar,  rice  and  barley  gruel  with- 
out milk,  and  later  albumin  milk  with  equal  parts  of  barley  or  rice 
water).    In  the  beginning  the  bowels  should  be  cleansed  with  a  mod- 
erate dose  of  castor  oil  or  syrupus  rhei  by  mouth  and  one  sterile  cool 
water  irrigation.     The   patient   is   then   put   on   pulveris   Doveri,   y^ 
grain,  for  every  year  of  the  child's  age  every  three  hours,  and  if  there 
is  no  vomiting  also  on  the  following  mixture : 
IJ     Bismuthi   Subnitratis 
Vini  Ipecacuanhae 
Mist.  Createe  Comp. 
Aq.    Anisi 
M. 
S. — One  teaspoonful  every  two  to  four  hours,  for  a 
child  three  years  old. 


3iv 

15.00 

3i 

4.00 

3iv 

15.00 

q.s.ad  f  5  iii 

90.00 

414  DISEASES    OP    CHILDREN 

In  severe  cases  the  intestines  should  be  irrigated  once  a  day  with 
1:1000  of  nitrate  of  silver,  and  once  a  day  with  1:1000  quinine  sul- 
phate solution,  the  latter  especially  in  amebic  dysentery.  The  irri- 
gation should  be  executed  very  gently  by  means  of  a  soft  rubber  catheter 
attached  to  an  ordinary  irrigator.  Sometimes  starch  water  (1  ounce  to 
1  pint)  with  a  few  drops  of  tincture  of  opium  will  relieve  the  tenesmus. 
Hydropathic  applications  to  the  abdomen  (plain  Priessnitz  compress,  or 
warm  turpentine  stupes)  are  useful. 

Flexner*  recommends  polyvalent  antidysenteric  serum  (10  to  20  c.c.) 
subcutaneously  or  intravenously. 

Collapse  should  be  combated  by  local  heat,  cognac,  red  wine  with  a 
hot  infusion  of  cinnamon,  camphor,  strychnine,  etc.  During  convales- 
cence care  in  dieting  is  still  demanded  (recurrences  are  common), 
and  the  persistent  anemia  calls  for  iron,  analeptics  in  the  form  of 
strengthening  food  (fresh  eggs,  milk  with  cereals,  broths,  etc.)  and 
plenty  of  fresh  air,  and,  whenever  possible,  a  sojourn  in  the  country, 
preferably  at  the  seashore. 

In  amebic  dysentery  quinine  (2  to  5  grains  t.  i.  d.)  by  mouth,  and 
emetine  hydrochlorate  (%  grain)  hypodermically  once  a  day  are  of  great 
service. 

In  chronic  dysentery  the  tannates  in  conjunction  with  the  quinine 
and  silver  irrigations  do  better  than  the  bismuth  preparations.  Other- 
wise the  management  is  the  same  as  in  acute  dysentery.  The  more  pro- 
tracted the  course,  the  greater  the  exhaustion  and  loss  of  blood ;  and  the 
younger  the  child,  the  worse  the  prognosis.  The  mortality  in  different 
epidemics  varied  between  5  per  cent  and  30  per  cent.  Early  attention 
is  a  very  great  factor  in  reducing  the  mortality  and  the  tendency  toward 
chronicity. 

Rheumatismus  Acutus 

(Rheumatic  Fever,  Polyarthritis  Acuta) 
Acute  inflammatory  rheumatism  is  an  infectious  disease  with  a  spe- 
cific predilection  for  the  fibrous  tissues  and  serous  membranes.  The 
muscular  and  neural  structures,  however,  are  not  exempt  from  it. 
The  discovery  of  the  rheumatism-producing  microorganism  is  a  mat- 
ter probably  of  the  very  near  future.  In  fact  it  is  quite  probable  that 
the  so-called  streptococcus  or  diplococcus  rheumaticus  which  is  fre- 
quently found  in  the  exudate  of  the  joints  and  in  the  blood  plays  a 
very  important  role  in  the  causation  of  rheumatic  fever. 

Rheumatism  is  most  common  in  children  over  five  years  of  age,  but 
no  age  (even  infants  under  one  year)  is  exempt.  A  hereditary  dis- 
position can  usually  be  traced  in  the  majority  ot  cases. 


"Jour.  Am.  Med.  Assn.,  Ixxvi,  No.  2,  1921. 


SPECIFIC    COMMUNICABLE   DISEASES  415 

Similar  to  other  infectious  diseases,  rheumatic  fever  is  most  prev- 
alent in  certain  climates  and  seasons  of  the  year.  It  presents  a  pro- 
dromic  stage  of  variable  duration,  which  is  characterized  by  chilli- 
ness, languor,  etc.  Like  the  eruptive  fevers  it  is  manifested  by  gen- 
eral febrile  disturbance  with  local  lesions.  To  a  certain  extent  it  is 
self-limited,  since  with  exhaustion  of  the  fertile  soil  in  one  place,  the 
inflammation  "jumps"  to  another  place.  It  ordinarily  yields  promptly 
to  specific  medication ;  in  this  respect  also  resembling  infectious  fevers, 
e.  g.,  malarial  fever. 

After  a  brief  prodromic  stage,  the  symptoms  of  acute  rheumatism 
usually  set  in  suddenly,  with  chills,  rise  of  temperature,  vomiting, 
and  vague  pain  in  several  parts  of  the  body.  In  very  young  children 
the  onset  is  not  rarely  associated  with  cerebral  symptoms,  especially 
convulsions.  Older  children  often  complain  of  sore  throat  (lacunar 
tonsillitis),  and  in  some  cases  articular  swelling  forms  the  first  prin- 
cipal manifestation  of  the  affection.  The  disease,  once  established, 
differs  in  its  symptomatology  and  course  but  little  from  that  observed 
in  rheumatism  in  adults,  except,  as  will  be  seen  later,  that  in  children 
there  is  a  greater  tendency  toward  cardiac  complications,  while  the 
articular  involvement  is  usually  less  pronounced. 

The  joints  of  the  knee,  ankle,  elbow  and  wrist  are  most  commonly 
affected,  occasionally  also  those  of  the  phalanges  and  hip.  In  one  case 
under  observation  the  lower  dorsal  vertebrae  were  so  severely  affected 
as  to  greatly  resemble  acute  spondylitis.  The  articular  involvement 
is  accompanied  by  stiffness,  slight  redness,  swelling  and  excruciating 
pain,  the  latter  especially  on  attempting  to  walk,  or  moving  or  hand- 
ling the  parts  affected.  The  inflammation  may  abruptly  cease  at  one 
or  more  joints  and,  as  suddenly,  attack  others.  During  the  acute 
stage  the  temperature  varies  between  102°  and  104°  F.,  and  as  the 
inflammation  "jumps"  from  joint  to  joint  there  is  usually  a  sharp 
rise  of  temperature.  Correspondingly,  the  temperature  falls  with 
abatement  of  the  local  manifestations.  The  urine  is  usually  scanty 
and  high-colored,  filled  with  urates,  and  occasionally  contains  traces 
of  albumin.  The  characteristic  sour  (lactic  acid)  sweats  observed  in 
adults  are  much  less  pronounced  in  children. 

There  is  no  definite  limitation  to  the  duration  and  course  of  the 
affection.  Mild  cases,  after  pursuing  a  mild  febrile  course  for  a  few 
days,  may  either  recover  entirely  or  enter  into  a  subacute,  afebrile 
stage,  which  for  weeks  and  months  may  be  manifested  by  vague  ar- 
ticular and  muscular  pain,  and  ultimately  end  either  in  complete  re- 
covery, or  leave  behind  some  form  of  subacute  or  chronic  heart  dis- 


416  DISEASES    OF    CHILDREN 

ease.  Indeed,  it  is  usually  in  such  eases  that  the  heart  affection  is 
overlooked,  and  unexpectedly  discovered  some  time  (years!)  later,  with- 
out being  able  to  disclose  a  rheumatic  history.  Severe  cases  may 
run  a  febrile  course  of  from  three  to  five  weeks  and  sometimes  as  many 
months,  if  left  untreated.  It  is  w^ell  to  remember  that  the  gravity 
of  an  attack  is  not  always  commensurate  with  the  severity  of  the 
articular  involvement.  In  quite  a  number  of  cases,  endocarditis  or 
pericarditis,  or  both,  may  predominate  while  the  other  symptoms 
are  barely  noticeable.  Hence  the  importance  of  a  routine  and  care- 
ful examination  of  the  heart  of  children  suffering  from  rheumatic 
and  ''growing"  pain,  or  chorea.  The  latter  disease,  b}^  the  way,  is 
closely  allied  to,  and  may  precede,  accompany  or  follow  rheumatism 
in  its  various  forms.     (See  ''Chorea".) 

The  earliest  symptoms  of  rheumatic  endocarditis  are  increase  of 
frequency  and  intensity  of  the  heart  beat  and  precordial  pain.  This 
is  soon  followed  by  the  usual  physical  signs  of  endocarditis — those 
of  mitral  regurgitation  predominating.  Endocarditis  forms  the  most 
frequent  (in  about  60  per  cent)  complication  of  inflammatory  rheu- 
matism and  usually  sets  in  within  the  first  ten  days  from  the  onset. 

Pericarditis  is  observed  only  in  about  10  per  cent  of  the  cases,  and 
somewhat  later  than  endocarditis.  It  is  manifested  by  a  dry  friction 
sound,  heard  at  the  apex  or  base  of  the  heart,  or  by  a  serous  exuda- 
tion which  may  rapidly,  and  unnoticeably,  disappear,  or  persist  and 
lead  to  pericardial  adhesions  and  their  accompanying  more  or  less 
grave  sequelae. 

Less  frequent  complications  are  pleuritis  and  pneumonitis.  Both 
these  affections  are  ordinarily  limited  to  the  left  side.  The  pleuritic 
effusion  may  be  serous  or  serofibrinous  and  is  most  frequently  asso- 
ciated with  pericarditis.  Of  still  less  frequent  occurrence  are  perito- 
nitis and  nephritis.  The  abdominal  pain,  however,  not  infrequently 
complained  of  by  children  during  an  attack  of  rheumatism,  is  usually 
due  to  muscular  hyperesthesia  and  not  to  peritoneal  involvement. 

As  in  adults,  rheumatism  of  children  may  also  affect  the  muscles. 
Rheumatic  torticollis  is  especially  common,  and  in  severe  cases  is 
apt  to  be  mistaken  for  cervical  spondylitis.  Muscular  rheumatism 
affecting  the  muscles  of  the  lumbar  region  may  resemble  lumbar  spon- 
dylitis; and  that  of  the  leg  may  give  rise  to  symptoms  (pain  on  motion, 
lameness,  stiffness,  etc.)  simulating  coxitis,  or  poliomyelitis.  As  pre- 
viously mentioned,  rheumatism  of  the  abdominal  muscles  may  simulate 
peritonitis,  while  rheumatism  of  the  intercostal  muscles  may  be  mis- 
taken for  dry  pleurisy.     In  all  these  cases  a  diagnosis  can  usually  be 


SPECIFIC    COMMUNICABLE   DISEASES  417 

arrived  at  by  bearing  in  mind  the  pathognomonic  symptoms  of  the 
affections  the  muscular  rhenmatism  resembles,  and  the  fact  that  the 
latter  promptly  yields  to  the  salicylates,  and  that  as  a  rule,  there  is  a 
history  of  involvement  of  other  groups  of  muscles. 

Eheumatism  may  also  affect  the  periosteum  and  give  rise  to  thick- 
ening of  the  underlying  bone  which  condition  with  the  accompanying 
pain  and  fever,  may  simulate  incipient  osteomyelitis.     From  what  has 


Fig.  93. — Rheumatic  torticollis  of  several  weeks'  duration  in  a  child  six  years  old 
which  greatly  resembled   cervical   spondylitis. 

been  said,  it  can  readily  be  seen  that  the  diagnosis  of  rheumatism  in 
its  various  phases  is  far  from  being  easy. 

Moreover,  articular  rheumatism  may  also  be  mistaken  for  syphilitic, 
gonorrheal,  tuberculous,  and  the  so-called  septic  arthritides,  scurvy 
and  its  allied  affections. 

In  our  endeavor  to  differentiate  rheumatism  from  the  divers  forms 
of  articular  and  periarticular  inflammations,  we  must  bear  in  mind 


418  DISEASES   OP    CHILDREN 

that  rheumatism  is  a  primary  febrile  affection,  as  a  rule,  sudden  in 
development;  that  its  inflammatory  process  is  transient,  and  its  local- 
ization multifarious  and  rapidly  shifting,  and,  finally,  that  its  course 
is  promptly  and  often  permanently  influenced  by  the  salicylates. 

Differential  Diagnosis 

Epiphysitis  Syphilitica. — Syphilitic  epiphysitis  develops  slowly,  in 
the  first  few  months  of  life — rather  exceptional  for  rheumatism — in  as- 
sociation with  other  symptoms  of  congenital  syphilis.  It  runs  an 
afebrile  course  and  yields  promptly  to  antisyphilitic  medication. 

Arthritis  Heredosyphilitica  (Tarda). — Hereditary  syphilitic  arthritis 
develops  gradually,  and  affects  principally  one  or  both  knees.  It  is 
usually  associated  with  other  syphilitic  symptoms,  especially  intersti- 
tial keratitis.  As  a  rule,  the  subjective  disturbances  are  incongruous 
with  the  severity  and  extent  of  the  local  signs,  and  the  arthritis  is 
but  rarely  accompanied  by  inflammatory  symptoms.  It  yields  promptly 
to  antisyphilitic  medication.  Puncture  of  the  swelling  reveals  sero- 
fibrinous fluid  and  not  rarely  the  spirochete. 

Arthritis  Gonorrheica. — Gonorrheal  arthritis  occurs  as  a  complica- 
tion of  gonorrheal  ophthalmia,  urethritis,  or  vulvovaginitis.  It  is  most 
frequently  limited  to  one  knee,  more  rarely  to  both  knees,  or  to  the 
maxillary  or  sternal  articulations,  and  is  accompanied  by  pronounced 
inflammatory  local  and  general  symptoms.  The  articular  involvement 
is  more  lasting  than  that  of  acute  rheumatism,  and  resists  antirheu- 
matic measures. 

Arthritis  Tuberculosa. — Tuberculous  arthritis  develops  gradually, 
usually  remains  limited  to  one  joint,  and  resists  antirheumatic  treat- 
ment. Atrophy  of  the  affected  limb  sets  in  early,  and  an  x-ray  ex- 
amination often  shows  involvement  of  the  bone.  The  tuberculin  reaction 
is  often  positive. 

Arthritis  Septica. — Septic  or  infective  arthritis  is  usually  monoarticu- 
lar and  arises  secondarily  to  sepsis  (e.  g.,  purulent  arthritis  in  sepsis 
neonatorum)  or  to  acute  infectious  diseases,  such  as  typhoid  fever,  in- 
fluenza, pneumonia,  diphtheria,  scarlatina,  etc.  In  two  cases  under  our 
observation  purulent  arthritis  of  the  knee  followed  tonsillectomy.  The 
history  is  the  most  reliable  clue  in  the  diagnosis,  and  the  finding  of  the 
streptococcus,  pneumococcus,  etc.,  in  the  seropurulent  fluid  obtained 
by  exploratory  puncture  of  the  swelling  is  decisive. 

Scorbutus  (Barlow's  disease)  purpura  hemorrhagica  and  hemophilia 
(with  sanguineous  effusion  into  the  joints)  also  may  be  mistaken  for 
acute  articular  rheumatism.  In  the  hemorrhagic  diseases,  however, 
tlji.er.e  ^re  hemorrhages  from  and  into  other  parts  of  the  body.     The 


SPECIFIC    COMMUNICABLE   DISEASES  419 

articular  swelling  is  not  as  evanescent.  Fever  is  usually  absent  or 
slight.  Furthermore,  Barlow's  disease  is  observed  in  very  young  in- 
fants, who  are  rarely  attacked  by  rheumatism,  and  yields  promptly  to 
antiscorbutic  diet.    Antirheumatic  treatment  is  futile. 

Osteomyelitis. — The  swelling  does  not  appear  until  a  few  days  after 
the  onset  of  the  disease,  and  has  its  center,  not  opposite  the  joint,  as  in 
articular  rheumatism,  but  above  or  below,  opposite  one  or  other  of  the 
epiphyses  of  the  bones  entering  into  the  formation  of  the  joint.  In 
advanced  cases  the  SAvelling  extends  along  the  shaft  to  a  variable 
distance.  In  contrast  to  osteomyelitis  rheumatism  is  rarely  limited 
to  a  single  joint,  and  its  sw^elling  never  suppurates.  Leucocytosis  is 
absent  in  rheumatism,  and,  as  a  rule,  marked  in  osteomyelitis.  A 
skiagraph  is  helpful  in  the  differential  diagnosis. 

Prognosis. — Rheumatic  fever  per  se  is  very  rarely  fatal,  but  only  very 
few  patients  emerge  uninjured  from  a  severe  attack  of  rheumatism.  In 
probably  two-thirds  of  the  cases  some  form  of  heart  disease  is  acquired, 
which  sooner  or  later  manifests  evidence  of  its  destructive  character. 
This  obtains  particularly  in  recurrent  rheumatism,  as  well  as  in  cases 
improperly  cared  for,  as  regards  rest  and  specific  medication. 

Treatment. — Rest  in  bed  is  the  most  important  therapeutic  measure 
in  the  prevention  of  grave  complications  and  sequelae,  and  should  be 
enjoined  at  least  during  the  febrile  course  of  the  disease.  Medicinally, 
the  salicylates  act  specifically  in  all  acute  rheumatic  conditions,  and 
their  administrations  should  be  continued  until  every  vestige  of  the 
disease  has  disappeared.  In  the  beginning,  the  salicylates  should  be 
pushed  to  their  full  tolerance — let  us  say  1  grain  of  the  sodium  salicy- 
late for  every  year  of  the  child's  age,  every  two  hours,  until  the  acute 
symptoms  have  been  arrested,  then  every  three  or  six  hours  according 
to  indications.  The  salicylates  may  be  alternated  with  sodium  bi- 
carbonate until  the  urine  becomes  alkaline,  or  with  atophan.  With  the 
appearance  of  cardiac  complications,  the  iodides,  in  small  doses,  should 
be  added,  and  if  necessary,  also  digitalis.  For  the  relief  of  articular  pain 
and  swelling,  the  joint  should  be  enveloped  in  absorbent  cotton  wrung 
out  of  a  saturated  solution  of  bicarbonate  of  soda.  The  compress  should 
be  covered  with  oiled  silk  and  a  flannel  bandage  and  changed  every 
two  to  four  hours.  When  the  pain  is  very  acute  I  have  found  the 
following  very  serviceable: 


Olei  GaultheriiB 

Guaiacolis 

Ichthyolis                          aa  3  ss 

2.00 

Adipis  Lanse                          5  i 

30.00 

S. — Apply  gently   twice   a  day,  and     'r  ■■' 

cover  with  a  flannel  bandage. 

«<  ')>i« 

420  DISEASES    OF    CHILDREN 

Acute  rheumatism  being  an  infectious  disease,  I  have  no  faith  in 
"mathematical  dietetics"  as  a  cure  of  the  disease;  hence,  do  not 
employ  any  specific  dietary,  but  limit  the  diet  to  a  so-called  "fever 
diet"  during  the  febrile  stage  of  the  disease  and  to  easily  digestible 
food  of  all  sorts  later.  This  has  the  advantage  of  maintaining  the  nu- 
trition of  the  patient  who  at  best  is  weak  and  anemic.  On  the  other 
hand,  in  a  number  of  refractory  cases  the  diet  has  to  be  limited,  and 
I  have  found  that  a  purely  vegetable  and  cereal  diet  (without  milk 
or  sugar,  but  made  palatable  by  the  addition  of  sweet  butter)  will 
often  be  very  beneficial.  The  prolonged  use  of  the  iodides  and  cod 
liver  oil  is  always  in  order  in  the  convalescent  stage,  and  a  sojourn 
in  a  dry  and  high  inland  resort  will  prevent  recurrence  and  chronicity. 

3J     Natrii  Salicyl  3  ii  8.00 

Mist.  Ehei  et  Sodse  3  iii  12.00 

Aq.  Destil.  q.  s.  ad  f  S  iii  90.00 

M. 

S. — One  teaspoonful  every  two  to  four  hours,  for 

a  child  four  years  old. 

IJ     Antipyrinae                                            3  ss  2.00 

Natrii  Salicyl.                                     3  iss  6.00 

Caffeinse  Natrii  Benzoatis           gr.  xvi  1.00 

Syr.  Simplicis                                        3  iv  15.00 

Aq.  Destil.                               q.  s.  ad  f  5  ii  60.00 
M. 

S. — One   teaspoonful   every   six   to   twelve  hours, 

for  a  child  four  years  old  (for  quick  relief  of  pain.) 

IJ     Olei  gaultherisB  3  i     I     4.00 

Ft.  caps.  no.  xii. 
S. — One   capsule   every   four   to   six  hours,   for   a 
child  six  years  old  (for  subacute  rheumatism). 

The  throat  should  be  kept  disinfected  by  Dobell's  or  similar  anti- 
septics.   Constipation  should  be  remedied  by  cascara  sagrada. 

Recurrent  rheumatism  often  calls  for  complete  enucleation  of  the 
tonsils,  and  careful  attention  to  the  teeth. 

Rheumatoid  Arthritis 

( Rheum ATisMus  Chronicus,  Arthritis  Deformans) 

Chronic  rheumatism  in  children  is  very  rare.  Similar  to  what  oc- 
curs in  adults,  it  may  supervene  after  recurrent  attacks  of  acute  or 
subacute  rheumatism,  or,  very  exceptionally,  it  may  develop  primarily. 
In  either  case  the  local  manifestations  are  clinically  alike,  and  consist 


SPECIFIC    COMMUNICABLE   DISEASES  421 

of  gradual  enlargement  of  the  affected  joints,  with  atrophy  of  the 
muscles  around  the  joints,  painful  and  hindered  motility,  ankylosis, 
and  deformity  of  the  bones  at  the  articulations.  It  is  usually  bilateral. 
The  course  of  this  form  of  rheumatism  though  very  protracted,  and 
extending  over  a  period  of  years,  is  usually  not  as  slow  as  in  adults. 
It  eventually  leads  to  crippling  of  the  patients,  and  fatal  termination 
either  from  exhaustion  or  complicating  tuberculosis. 

Chronic  articular  rheumatism  may  be  confounded  principally  with 
syphilitic  and  tuberculous  affections  of  the  joints.  Syphilitic  arthritis 
is  usually  accompanied  by  other  syphilitic  symptoms,  especially  kera- 
titis, and  ordinarily  yields  to  antisyphilitic  treatment.  The  differen- 
tiation between  simple  chronic  arthritis  and  tuberculous  joints  is 
quite  difficult,  since,  as  previously  mentioned,  the  latter  may  follow 
the  former.  However,  the  absence  of  temperature  and  failure  to  ob- 
tain a  positive  tuberculin  reaction,  speak  in  favor  of  chronic  non- 
tuberculous  arthritis.  The  finding  of  a  tuberculous  exudation  in  the 
affected  joint,  of  course,  is  decisive  in  the  diagnosis. 

As  the  prognosis  in  protracted  cases  is  very  bad,  active  treatment 
should  be  begun  early  and  not  too  rapidly  discontinued,  in  disgust, 
because  of  more  or  less  persistent  failure  to  effect  a  cure.  The  salicy- 
lates with  small  doses  of  sodium  iodide  internally  and  50  per  cent  ichthyol 
ointment  externally  should  be  given  a  thorough  trial.  Where  stiffness 
and  swelling  of  the  joints  prevail,  daily  gentle  massage  preceded  by  a  hot 
local  ba,th  and  followed  by  hot  moist  compresses  often  works  wonders. 
Passive  motion  should  be  practiced  early,  and  where  the  contractures 
are  very  pronounced  one  should  not  hesitate  to  reduce  the  same  under 
primary  anesthesia  and  proceed  with  the  treatment  just  outlined. 
Concomitant  acute  symptoms  should  be  treated  in  the  same  manner 
as  in  acute  rheumatism,  and  w^hen  there  is  reason  to  believe  that  the 
diseased  condition  is  the  result  of  faulty  metabolism  (intestinal  in- 
toxication or  uric  acid  diathesis),  the  dietary  should  be  regulated  ac- 
cordingly (exclusion  of  meats,  acids,  liquors,  etc.).  Hypertrophied 
tonsils  should  be  promptly  enucleated,  and  decayed  teeth,  which  can- 
not be  filled,  removed. 

'^     Natrii  lodidi 

Ext.  Hyoseiami  Fl. 

Natrii  Salicyl 

Syr.  Sarsaparilla)  Comp. 

Aq.  Destil. 

M. 
S. — One  teaspoonful  every  four  hours,  for  a  child 
four  years  old. 


gr.  XV 

1.00 

m.  vi 

0.40 

3i 

4.00 

Si 

30.00 

q.  s.  ad  f  B  iii 

90.00 

422  '  DISEASES    OF    CHILDREN 

Still's  Disease 

This  affection  generally  sets  in  during  the  first  three  or  four  years 
of  life  and  attacks  girls  more  frequently  than  boys.  It  is  characterized 
by  gradually  developing  stiffness  and  enlargement  of  several  joints, 
beginning  with  the  knee,  wrists  and  cervical  vertebrae,  and  gradually 
extending  to  the  fingers  and  toes.  It  differs  pathologically  from 
rheumatoid  arthritis  or  tuberculosis  in  that  it  is  free  from  destructive 
or  proliferating  processes  of  the  bony  structures.  As  may  be  readily 
determined  by  the  roentgen  ray  examination,  the  enlargement  of  the 
joints  is  due  purely  to  thickening  of  the  soft  tissues.  Aside  from  the 
articular  involvement.  Still's  disease  is  characterized  by  a  more  or 
less  marked  enlargement  of  the  lymphatic  glands  (axillary,  cervical 
and  mesenteric)  and  of  the  liver  and  spleen.  It  is  occasionally  asso- 
ciated with  a  slight  rise  of  temperature,  and  shows  a  tendency  to 
pericardial  and  pleural  affections. 

It  is  a  very  chronic,  incurable  affection  of  unknown  etiology.  Its 
progress  may  be  partially  arrested  by  the  therapeutic  measures  out- 
lined under  ''Chronic  Rheumatism", 

Rheumatismus  Nodosus  Infantilis,  Erythema  Nodosum,  Peliosis  Rheu- 
matica  (Purpura  Rheumatica) 

These  three  distinct  diseased  conditions  are  grouped  together  to 
facilitate  their  identification.  They  have  several  symptoms  in  com- 
mon, and  bear  a  close  resemblance  to  rheumatism.  Their  true  nature, 
however,  is  a  matter  of  conjecture,  and  with  our  present  ignorance 
as  to  the  identity  of  the  specific  rheumatic  germ,  there  are  no  means 
of  corroboration  or  of  contradiction  of  any  of  the  numerous  assump- 
tions advanced  by  different  authorities. 

Rheumatismus  Nodosus  Infantilis 

This  disease  is  peculiar  to  early  childhood  and  occasionally  follows 
a  protracted  or  recurrent  attack  of  rheumatism,  especially  in  asso- 
ciation with  grave  cardiac  manifestations.  It  is  characterized  by 
the  (often  symmetrical)  appearance,  chiefly  about  the  joints  and  the 
tendon  insertions,  of  several  nodules  {noduli  or  osteomata  rheumatici) 
which  grow  to  a  perceptible  size,  and  then  either  undergo  regressive, 
fatty  metamorphosis  and  absorption,  or  persist,  become  calcified  and 
acquire  a  bony  consistence.  The  nodules  (exotoses)  vary  in  size 
from  a  small  pea  to  a  plum  and  in  number  from  one  to  a  hundred. 
They  are  at  first  soft,  flat  and  painful  or  tender  to  the  touch,  and  later 
they  become  harder  and  rounder,  resembling  the  fibromatous  and  osteo- 


SPECIFIC    COMMUNICABLE   DISEASES 


423 


Fig.  94 


Fig.  95  Fig.  96 

Still's  Disease  in  a  boy  five  years  old.     (G.  R.  Pisek.) 

Fig.  94. — Showing  the  arthritis  being  multiple. 

Fig.  95. — Periarticular  changes  in  the  left  wrist  joint. 

Fig.  96. — Symmetrical  changes  in  the  periarticular  soft  parts  of  the  knees  and 


ankles. 


424  DISEASES   OP    CHILDREN 

matoiis  growths  observed  in  "Myositis  Ossifieaiis"  and  in  "Multiple 
Exostoses"  (q.v.). 
Treatment. — Antirheumatic. 

Erythema  Nodosum 

Until  recently  this  affection  has  been  looked  upon  as  a  skin  dis- 
ease pure  and  simple.  The  sudden  appearance,  the  rise  of  temperature, 
the  self-limited  course,  and  its  association  with  more  or  less  marked 
constitutional  symptoms  and  occasionally  grave  complications  (prin- 
cipally rheumatic  pain,  bleeding  from  mucous  membranes  and  heart 
trouble),  stamp  it,  however,  as  an  acute  infectious  disease  of  obscure 
etiology.  Locally,  it  is  characterized  by  the  appearance,  chiefly  on 
the  anterior  portion  of  the  lower  legs  and  forearms,  of  from  a  pea-  to  a 
w^alnut-sized,  pale  red,  painful  nodules  which  at  first  resemble  con- 
tusions (erythema  contusiforme).  They  gradually  disappear,  changing 
in  color  to  bluish,  green  and  yellow  within  from  two  to  three  weeks, 
as  a  rule,  without  any  specific  medication. 

Treatment. — Complications  of  the  heart  and  joints  demand  anti- 
rheumatic treatment. 

Peliosis  (Purpura)  Rheumatica 

(Schonlein's  Disease) 

The  local  manifestations  of  this  affection  consist  of  variously  sized 
bright-  to  bluish-red  hemorrhagic  spots  which  are  uninfluenced  by 
pressure  with  the  finger.  Here  and  there  they  present  a  central 
papular  hardness.  The  eruption  is  usually  limited  to  the  lower  ex- 
tremities, especially  about  the  knees  and  ankles,  but  the  upper  ex- 
tremities may  be  affected  as  well.  The  appearance  of  the  eruption  is 
preceded  and  accompanied  by  urticaria,  articular  pain  and  swelling, 
occasionally  soreness  of  the  soles  of  the  feet,  and  difficulty  in  walking. 
Fever  and  constitutional  symptoms  are  ordinarily  slight.  Occasionally 
we  find  edema  of  the  face^  slight  intestinal  hemorrhage  and  enlarge- 
ment of  the  spleen.  The  hemorrhagic  spots  usually  disappear  in  from 
ten  to  fourteen  days. 

The  prognosis  is  usually  favorable,  but  the  disease  manifests  a 
tendency  to  recurrences,  and  to  cardiac  complications. 

Treatment. — Symptomatic:  salicylates;  daily  intestinal  irrigation 
with  a  warm  bicarbonate  of  soda  solution  (one  ounce  to  1  quart  of 
water)  ;  rest  in  bed.    Light  diet. 


SPECIFIC    COMMUNICABLE   DISEASES  425 

Myositis 

(Inflammation  of  the  Muscles) 

The  causes  of  myositis  are  very  numerous.  We  had  occasion  to 
refer  to  scarlatinal  and  rheumatic  myositis.  It  may  also  be  trau- 
matic, gonorrheal,  syphilitic  and  tuberculous  in  nature,  and  is  occa- 
sionally observed  in  connection  -with  other  infectious  disease,  e.  g., 
typhoid.  Myositis  is  characterized  by  pain,  swelling  and  loss  of 
function  of  the  affected  muscles,  and,  in  protracted  cases,  by  con- 
tractures. Where  pain  predominates  and  the  swelling  is  slight,  myo- 
sitis may  readily  lead  to  diagnostic  errors,  as  emphasized  in  the  discus- 
sion of  ''Muscular  Rheumatism."  (See  p.  416.)  Traumatic,  syphilitic 
and  tuberculous  myositides  are  prone  to  lead  to  suppuration,  while 
simple  so-called  rheumatic  myositis  eventually  subsides  either  spon- 
taneously or  under  antirheumatic  treatment. 

Poljnmyositis 

This  form  of  general  myositis  is  of  much  graver  nature  than  the  afore- 
mentioned varieties.  It  occurs  either  primarily,  without  any  apparent 
cause,  or  secondarily  as  a  result  of  parasitic  infection,  such  as  trichinae, 
echinococci,  cysticerci,  etc. 

Preceded  by  prodromata  of  a  few  days'  duration,  consisting  of  head- 
ache, muscular  pain,  anorexia,  and  slight  fever,  the  condition  rapidly 
grows  worse;  the  temperature  rises,  and  edema  of  the  eyelids  and  face 
appears  which  soon  spreads  over  the  entire  body.  Beginning  also  with 
the  face,  the  entire  musculature  of  the  body  (least  marked  in  the  hands 
and  feet)  rapidly  becomes  stiff,  board-like,  and  very  painful,  so  much 
so  that  the  different  functions  of  the  body  (mastication,  deglutition, 
respiration,  etc.)  are  interfered  with  and  the  condition  greatly  re- 
sembles that  of  cerebral  rigidity. 

In  some  cases  cutaneous  edema  predominates  (dermatomyositis) ,  in 
others  a  hemorrhagic  condition  of  the  skin  and  mucous  membrane  {poly- 
myositis hemorrhagica).  Some  cases  develop  very  slowly  and  lead  to 
overgrowth  of  the  connective  tissue  {myositis  fibrosa).  In  trichiniasis 
the  polymyositis  is  usually  preceded  by  gastrointestinal  disturbance,  and 
the  stools  and  the  muscles  reveal  trichinaB  spiralis.  The  blood  shows 
marked  eosinophilia. 

In  children  the  course  of  the  disease  is  usually  milder  than  in  adults 
and,  as  a  rule,  ends  in  recovery. 

Treatment. — Symptomatic:   thorough   cleansing   of   the   alimentary 


426  DISEASES   OF    CHIIiDREN 

tract;  relief  of  pain  by  antispasmodics,  and,  in  trichiniasis,  large  doses 
(tablespoonful  every  3  or  4  hours)  of  glycerine. 

Myositis  Ossificans 

Myositis  ossificans  multiplex  progressiva  is  a  disease  of  childhood, 
the  majority  of  the  cases  on  record  having  been  observed  in  children 
under  ten  years  of  age.  Anatomically,  it  is  characterized  by  pro- 
gressive interstitial  connective-tissue  proliferation,  with  consecutive 
ossification.  The  alfection  begins  with  the  muscles  of  the  neck  and 
back,  then  spreads  to  those  of  the  extremities,  and,  finally,  involves 
the  masseter  and  temporal  muscles. 

The  etiology  of  the  disease  is  unknown. 

The  onset  is  sudden  with  fever,  and  a  soft,  painful  swelling  of  a 
section  of  a  muscle,  over  which  the  skin  appears  reddened  and  edema- 
tous. 

The  febrile  symptoms  soon  abate,  but  the  swelling  in  the  muscle 
persists,  and  gradually — it  sometimes  takes  years — assumes  a  bony 
consistence.  Several  muscles  may  thus  become  affected,  leading  to 
disturbance  of  motion,  rigidity  and  deformities,  and  ossification  of 
a  large  portion  of  the  body  so  that  the  patient  becomes  bedridden 
for  life.  The  prognosis,  therefore,  is  grave,  and  life  is  endangered 
early  if  the  muscles  of  mastication  and  respiration  are  involved. 

Treatment. — Avoidance  of  traumatism;  the  salicylates  and  the  io- 
dides internally  and  externally;  gentle  massage  and  hot  baths. 

Multiple  Exostoses 

Bone  tumors  in  children  may  be  congenital  or  acquired.  The  latter 
variety  has  been  spoken  of  in  connection  with  rheumatism.  (See  p. 
422.)  Congenital  exostosis  may  escape  observation  for  several  years 
and  then  erroneously  be  attributed  to  acquired  causes.  The  etiology 
of  congenital  exostosis  is  obscure.  Some  cases  are  traceable  to  syph- 
ilis hereditaria.  Some  authors  are  inclined  to  attribute  it  to  a  disorder 
of  growth.  Bone  tumors  localized  in  the  immediate  neighborhood  of 
joints  and  interfering  with  motility  should  be  extirpated.  Underbill 
(Jour.  Exp,  Med.,-  July,  1920)  among  others  suggests  that  in  the  early 
stages  of  cartilaginous  exostosis,  during  the  proliferative  cartilage 
changes,  the  progress  of  the  disease  may  possibly  be  checked  by  proper 
dietary  procedures,  and  especially  by  restriction  of  calcium  and  magne- 
sium intake. 


SPECIFIC    COMMUNICABLE   DISEASES 


427 


Fig.  97. — ^Multiple  exostoses.  The  tumors,  varying  in  size  from  a  pea  to  a  walnut, 
were  especially  numerous  at  the  eostosternal  articulations,  the  wrist-,  knee-  and 
ankle-joints. 

Meningitis  Cerebrospinalis,  see  p.  605. 

Poliomyelitis  Anterior,  see  p.  627. 

Encephalitis  Letharg-ica,  see  p.  624. 

Parotitis  Epidemica 

(Mumps) 

Primary,  idiopathic,  epidemic  parotitis  is  a  contagious  and  infec- 
tious affection  of  the  glandular  substance  (acini  and  the  ducts)  and 
the  interstitial  tissue  of  one  or  both  parotid  glands.  It  most  fre- 
quently attacks  children  of  from  two  to  twelve  years  of  age,  more 
rarely  younger  and  older  children.  One  attack  usually  confers  im- 
munity for  life. 

Secondary  or  metastatic  parotitis  is  not  rarely  met  as  a  complica- 
tion or  sequel  of  divers  infectious  diseases  and  has  nothing  in  com- 


428 


DISEASES   OF    CHILDREN 


mon  with  epidemic  parotitis.     Infection  occurs  through  the  mouth  or 
throat.     The  specific  microorganism  is  still  unknown. 

After  an  incubation  period  of  from  ten  to  twenty  days  and  a  pro- 
dromic  stage  of  about  forty-eight  hours'  duration  (marked  by  gen- 
eral malaise,  pain  in  the  region  of  the  ear  and  throat),  typical  epi- 
demic parotitis  is  characterized  by  a  gradually  increasing  swelling 
of  the  parotid  gland  in  front  and  below  the  ear  and  along  the  angle 
of  the  lower  jaw.  The  swelling  increases  up  to  the  third  or  fourth 
day,  remains  stationary  for  another  two  or  three  days,  and  then 
rapidly  subsides.     Quite  frequently  after  subsidiiig  in  one  parotid  the 


Fig.  98. — Epidemic  mumps. 

inflammation  passes  on  to  the  other;  more  rarely  both  parotids  are  in- 
volved simultaneously.  The  overlying  skin  is  usually  colorless;  more 
rarely,  pale  red,  glistening  and  painful.  Exceptionally  the  glands 
undergo  suppuration  (probably  due  to  mixed  infection!)  or  chronic  in- 
duration. The  inflammation  may  extend  to  the  other  salivary  glands,  or 
to  the  lymphatic  and  lacrimal  glands,  involving  the  tonsils,  lids,  con- 
junctiva, and  less  frequently  the  testicles,  or  ovaries,  vulva  or 
breast — usually  on  the  same  side  as  the  affected  parotid.  Occasion- 
ally the  submaxillary  glands  alone  are  involved,  and,  where  the  par- 
otitis is  bilateral  and  severe,  there  may  be  a  confluence  of  the  bilat- 
eral tumors. 


SPECIFIC    COMMUNICABLE   DISEASES  429 

Except  pain  in  swallowing,  in  opening  the  mouth,  chewing,  turn- 
ing the  head,  etc.,  headache,  occasionally  vomiting,  and  a  rise  of 
temperature  during  the  first  or  second  day  of  the  disease,  the  patient 
usually  suffers  no  discomfort.  Of  course,  the  sj'mptoms  are  materially 
changed  if  the  testicles  (orchitis  parotidea)  or  ovaries,  etc.,  are  in- 
volved, or  if  complications  make  their  appearance — rather  rarely 
to  be  observed  in  cases  of  ordinary  severity.  Otitis  and  nephritis  form 
the  most  frequent  complications.  They  may  occur  during  conva- 
lescence, less  often  during  the  acme  of  the  disease.  The  nephritis  is 
usually  hemorrhagic,  but  benign^  in  nature.  The  otitis  not  rarely 
leads  to  temporary  deafness.  Other  complications  of  parotitis  on 
record  are:  meningitis,  encephalitis,  divers  paralyses,  psychoses,  peri- 
carditis, endocarditis,  arthritis,  etc. — the  same  as  are  apt  to  be  met 
in  many  other  acute  contagious  and  infectious  diseases.  Notwith- 
standing the  possibility  of  grave  complications  and  sequelae,  the  prog- 
nosis of  parotitis  is  almost  always  favorable,  rarely  calling  for  any 
elaborate  therapeutic  measures. 

Treatment. — A  few  days'  rest  in  bed,  fluid  diet,  the  salicylates  for 
the  relief  of  pain,  and  local  application  of  lead  or  potassium  iodide 
ointment  with  or  without  10  per  cent  of  ichthyol,  or  oil  of  hyoscya- 
mus,  covered  with  absorbent  cotton,  usually  suffice  to  effect  a  cure 
in  the  majority  of  uncomplicated  cases.  Complications  should  be 
treated  according  to  indications.  Surgery  should  not  be  resorted  to 
unless  there  be  definite  signs  of  suppuration.  It  is  advisable  to  iso- 
late the  patient  for  about  three  weeks. 

Parotitis  may  be  mistaken  for  swellings  in  the  same  region  result- 
ing from  stomatitis,  alveolar  periostitis,  retropharyngeal  abscess,  and 
infected  glands  from  other  causes.  Bearing  in  mind  the  cause,  con- 
sistency and  location  of  the  tumor,  the  presence  or  absence  of  an 
epidemic,  and  the  course  and  duration  of  the  disease,  there  ought  not 
to  be  any  great  difficulty  in  arriving  at  a  correct  diagnosis. 

The  course  of  secondary  parotitis  differs  with  its  cause. 

Pertussis 

(TUSSIS    CONVULSIVA,   Whooping-cough  ) 

Whooping-cough  is  a  highly  communicable  epidemic  and  sporadic 
affection,  during  its  height  characterized  by  sudden  more  or  less  fre- 
quent paroxysms  of  coughing  which  are  from  time  to  time  interrupted 
by  deep,  stridulous  inspiration  and  followed  by  a  period  of  apparent 
euphoria  of  variable  duration.  The  specific  germ  of  the  disease  is 
still  unknown,  although  there  seems  ample  reason  for  the  belief  that 


430  DISEASES   OF    CHILDREN 

the  bacillus  described  by  Jochmann,  Krause,  Bordet  and  Gengoii  is  the 
immediate  cause  of  the  disease. 

As  a  rule,  the  course  of  pertussis  is  divisible  in  three  distinct  stages : 
stadium  catarrhale,  convulsivum  and  decrementi. 

The  stadium  catarrhale,  Avhich  lasts  about  ten  days,  begins  after  an 
incubation  period  of  from  five  to  nineteen  days.  It  is  sometimes  pre- 
ceded by  a  few  indefinite  prodromata,  consisting  of  loss  of  appetite, 
languor,  restless  sleep,  and  slight  fever;  and  as  these  symptoms  grad- 
ually disappear  they  become  replaced  by  those  of  a  simple  catarrh  of 
the  upper  air  passages,  so  that  the  advent  of  the  grip  or  measles  is 
often  suspected.  At  first  the  cough  is  short,  hacking,  sometimes 
croupy  in  character,  but  it  steadily  grows  worse,  although  returning 
at  longer  intervals.  It  is  especially  troublesome  at  night,  and  what, 
as  a  rule  is  particularly  characteristic  of  the  whooping-cough,  the 
cough  fails  to  respond  to  the  remedies  usually  efficient  in  ordinary 
"coughs  and  colds."  Toward  the  end  of  the  catarrhal  stage  the 
child  is  off  and  on  attacked  by  a  paroxysmal  loose  cough,  thus  indicating 
the  earl}'  advent  of  the  second,  convulsive  stage,  of  the  affection. 

The  stadium  convulsivum  may  last  from  two  to  four  weeks  or,  if  let 
run  at  random,  as  many  months.  The  cough  is  violent  and  explosive, 
each  paroxysm  being  often  preceded  by  a  slight  aura,  by  vomiting, 
sneezing,  etc.,  so  that  older  children  are  usually  aware  of  its  approach. 

Children  able  to  walk  usually  run  towards  a  person  or  object  to 
support  themselves  during  the  attack,  and  infants  manifest  the  ap- 
proach of  the  paroxysm  by  a  sudden  outburst  of  crying.  Each  par- 
oxysm which  lasts  from  one-half  to  five  minutes  consists  of  a  number 
of  short,  barking,  expiratory  acts  of  coughing,  from  time  to  time 
interrupted  by  deep  whistling  or  stridulous  inspirations — which  con- 
stitute the  "crow"  or  "whoop" — and  is  ordinarily  (sometimes  fol- 
fowed  by  a  second  or  third  fit  of  coughing)  concluded  with  the  ex- 
pulsion of  a  glassy,  tenacious  mucus  and  often  also  vomiting  of  food 
residue.  During  a  paroxysm  the  face  is  at  first  red,  then  cyanosed  and 
the  veins  in  the  neck  swell.  As  the  attacks  grow  worse,  there  is 
considerable  venous  stasis,  puffiness  of  the  face  (which  remains  oc- 
casionally permanent)  especially  at  the  eyelids;  there  may  be  bleed- 
ing from  the  nose  and  throat,  in  the  skin,  conjunctiva,  more  rarely 
from  the  ear  (rupture  of  the  drum  membrane,  which  heals  sponta- 
neously), in  the  meninges,  etc.  In  delicate  and  younger  children  a 
paroxysm  is  not  rarely  associated  with  involuntary  defecation  and 
urination,  and  at  times  also  with  general  convulsions.  The  number  of 
paroxysms  varies  between  ten  and  sixty  in  twenty-four  hours.     They 


SPECIFIC    COMMUNICABLE   DISEASES  431 

are  more  frequent  -when  the  patient  lives  in  unhygienic  surroundings, 
after  overloading  the  stomach,  on  excitement  from  any  cause  (cry- 
ing, laughing,  etc.),  irritation  of  the  nasopharynx  and  larynx,  etc. 
(often  a  useful  means  of  diagnosis!).  In  mild  and  moderately  severe 
eases  the  child  is  apparently  quite  well  between  the  attacks ;  in  very 
severe  eases,  however,  the  patient  is  weak,  pale,  emaciated  and  suffer- 
ing from  troublesome  bronchitis  and  often  from  a  number  of  the  other 
grave  complications  soon  to  be  related.  Under  proper  treatment  the 
paroxysms  in  uncomplicated  cases  are,  as  a  rule,  more  or  less  checked 
after  from  ten  to  twenty  days.  The  paroxj^smal  stage  is  then  followed 
by  the  regressive  stage,  stadium  decrementi.  The  attacks  become  less 
frequent,  they  lose  their  typical  character,  the  cough  returns  to  the 
original  catarrhal  type  and  finally  abates  entirely.  This  declining 
stage  ordinarily  lasts  from  two  to  three  weeks.  Occasionally,  how- 
ever, especially  in  cases  exposed  to  unsanitary  conditions  and  careless 
treatment,  this  stage  may  continue  for  months  and  be  interrupted  by 
relapses  which  often  undermine  the  patient's  constitution  and  lead 
to  irreparable  lesions  in  different  organs  of  the  body. 

Divers  complications  and  sequelae  have  been  noted:  Of  the  lungs: 
capillary  bronchitis,  bronchopneumonia,  emphysema,  and  bronchiec- 
tasis, phthisis  and  acute  miliary  tuberculosis  (as  a  result  of  caseation 
of  the  bronchial  glands)  ;  of  the  heart:  dilatation,  pericarditis,  and  myo- 
carditis; of  the  brain:  divers  paralyses  (hemiplegia,  facial,  laryngeal, 
etc.),  hemorrhagic  or  tuberculous  meningitis,  encephalitis,  softening  of 
the  brain,  mental  affections,  such  as  imbecility,  idiocy  and  different 
forms  of  insanity;  of  the  spinal  cord:  myelitis,  hemorrhagic  inflamma- 
tions, and  polyneuritis;  of  the  ears:  otitis,  with  or  without  permanent 
deafness;  of  the  eyes:  amblj'opia,  amaurosis;  also  nephritis,  sublingual 
ulceration  (as  a  result  of  friction  of  the  sublingual  tissues  against  the 
teeth  during  a  paroxysm)  severe  epistaxis,  and  emphysema  cutis  (pneu- 
mohypoderma,  q.  v.)  from  rupture  of  some  pulmonary  alveoli.  Delicate, 
especially  bottle-fed  babies,  not  rarely  suffer  from  gastroenteritis  with 
subsequent  marasmus.  Finally,  sudden  collapse  from  respiratory  and 
heart  failure  may  ensue  at  the  acme  of  a  protracted  fit  of  coughing. 

Fortunately,  the  cases  are  not  all  of  so  grave  a  nature  and  so  dread- 
ful in  their  consequences.  Numerous  abortive  cases  are  on  record  in 
which  the  second  stage  is  devoid  of  the  "whoop"  (sometimes  re- 
placed by  attacks  of  sneezing),  and  the  third  is  of  very  brief  duration, 
so  that  in  the  absence  of  an  epidemic  or  a  definite  source  of  infection 
there  is  justification  for  a  doubtful  diagnosis.  When  the  whoop  is 
absent,  some  assistance  in  the  diagnosis  may  be  obtained  by  a  careful 


432  DISEASES    OP    CHILDREN 

examination  of  the  blood,  which  will  show  that  during  the  second 
stage  the  polynuelear  cells  are  increased  twice  in  number,  and  the 
lymphocytes  about  four  times.  Of  diagnostic  importance  is  also  the 
fact  that  the  urine  has  a  high  specific  gravity  (1,022-32)  and  con- 
tains an  excessive  amount  of  uric  acid  crj^stals.  The  diagnosis  is  often 
almost  impossible  during  the  first  stage  of  the  affection  especially  if 
following  measles,  which  is  quite  frequently  the  case,  and  time  alone 
is  the  only  reliable  guide. 

No  other  communicable  affection  of  childhood  is  so  lightly  regarded 
by  the  laity  and  so  carelessly  treated  by  the  physician  as  that  under 
discussion.  Notwithstanding  the  fact  that  it  prevails  during  the 
greater  part  of  the  year ;  that  its  mortality  ranges  between  4  per  cent 
to  6  per  cent  as  an  immediate  result  of  the  disease,  and  at  least  as 
high  as  10  per  cent  in  consequence  of  complications  and  sequelae,* 
no  strenuous  effort  is  being  made  to  still  its  ravages,  to  arrest  its 
spread  or  to  abort  its  course.  The  fallacious  impression  has  gained 
firm  ground  that  whooping-cough  "must  run  its  course  of  from  six 
to  eighteen  weeks,"  and  even  the  scientific,  practical  physician  wisely 
nods  his  head  in  affirmation  and  despair,  lest  he  be  ridiculed  by  the 
therapeutic  nihilist.  One  has  to  be  bold  to  venture  to  claim  success 
in  allaying  the  spasm,  reducing  the  number  of  paroxysms,  and  pre- 
venting the  dreadful  complications  of  the  disease ;  and  the  one  who 
dares  to  proclaim  the  possibility  of  cutting  short  the  lengthy  course, 
courts  everlasting  infamy!  All  the  same,  the  severest  attack  of 
whooping-cough  properly  treated  may  be  rendered  almost  innocuous, 
or  at  least  free  from  grave  consequences. 

Treatment. — As  soon  as  pertussis  is  suspected  the  patient  should  be 
isolated,  and  given  pertussis  vaccines  (3  or  4  doses)  as  a  prophylactic. 
Immunization  should  also  be  resorted  to  in  all  the  other  children  coming 
in  contact  with  the  patient.    Isolation  should  be  practiced  principally 

•Statistics  compiled  by  Morse  from  the  United  States  Public  Health  Reports  show  that 
comparative  death  rates  per  hundred  thousand  are  as  follows: 

Whooping-Cough  11.4  per  cent. 

Scarlet    Fever    1 1 .6  per  cent. 

Measles   12.3  per  cent. 

Diphtheria 21.4  per  cent. 

He  states,  furthermore,  that  94.5  per  cent  of  the  deaths  from  whooping-cough  in  the  United 
States  occur  in  children  under  five  years  of  age,  as  follows: 

Under  one  year  of  age    57  per  cent. 

In   the   second   year    23   per  cent. 

In    the    third    year 8  per  cent. 

In   the   fourth   year    4  per  cent. 

In    the   fifth   year 2^^   per  cent. 

It  can,  therefore,  be  seen  that  the  mortality  from  whooping-cough  is  higher  in  those  of  tender 
years — being  more  than  twice  as  high  under  one  as  between  one  and  two;  and  more  than  five 
times  higher  under  two  years  than  between  two  and  five.  If,  to  these  statistics,  we  add  many 
of  the  reported  deaths  from  bronchopneumonia  supervening  on  whooping-cough,  the  mortality 
from  the  latter  would  be  still  larger. 


SPECIFIC    COM MI'NIC ABLE   DISEASES  433 

during  the  expectorating  period — at  least  three  weeks.  The  sputum 
should  be  collected  in  tissue  paper  or  gauze  and  immediately  destroyed. 
Fresh  air  being  the  most  essential  and  efficient  therapeutic  measure, 
the  child  should,  except  in  the  presence  of  grave  complications,  be 
kept  outdoors  the  greater  part  of  the  da}',  and  the  rooms  constantly 
aired  with  the  patient  indoors.  Whenever  possible,  two  or  more 
rooms  should  be  made  use  of.  The  food  should  be  bland  and  strength- 
ening, and  given  in  small  amounts,  preferably  after  the  paroxysms. 
The  clothing  should  correspond  with  the  season  of  the  year.  We  pos- 
sess no  ideal  specific  against  the  disease,  yet  pertussis  vaccine*  (in 
gradually  increasing  doses  from  500,000,000  to  2,500,000,000),  adminis- 
tered at  first  daily  and  later  once  or  twice  a  week,  undoubtedly 
influences  the  course  of  the  disease  very  favorably — even  though  not 
specifically.  Moreover,  a  great  deal  can  be  done  to  lessen  the  number 
and  severity  of  the  paroxysms  bj'  resorting  to  the  following  medicinal 
agents : 

IJ     Olei  Eucalypti                                         3  ii  8.00 

Tr.  Benzoini  Comp.               q.  s.  ad  f  B  ii  60.00 
M. 

S. — One  teaspoonful  in  a  pint  of  hot  water  to  be 

used  as  an   inhalation  through   a   croup   kettle  three 

times  a  day. 

IJ    Quinine  Ethyl  Carbonate  or 

Diquinine  Carbonic  Ester   (Euquinine 

or  Aristochin)  3  ss  2.00 

Syr.  Simplicis  3  ii  60.00 

M. 
S. — One   teaspoonful  every  two  to   four  hours,  ac- 
cording to  the  severity  of  the  paroxysms,  for  a  cliild 
three  years  old. 

In  older  children  the  subsulphate  of  quinine  or  qui- 
nine tannate  may  be  given  instead. 

T}i     Creosoti  Carbonatis  3  iv     I     15  00 

S. — Two  drops  for  every  year  of  the  child's  age. 

I  wish  to  direct  particular  attention  to  the  marked  antispasmodic 
value  of  calcium  and  sodium  hypophosphites  in  mitigating  and  often 
completely  arresting  the  "whoop"  of  pertussis.  I  have  been  led  to  ad- 
minister these  drugs  after  noting  the  close  resemblance  between  the 
manifestations  of  laryngeal  spasm  of  spasmophilia  (spasmus  glottidis) 
and  those  of  whooping  cough  and  observing  the  beneficent  action  of 
lime  and  soda  hypophosphites  in  spasmophilia.  Furthermore,  it 
seemed  to  me  quite  plausible  to  assume  that,  as  is  claimed  in  spasmo- 


*It   should   be   used   within    four    months    of    the    date    of    manufacture.      (W.    C.    Davison, 
Jour.  Am.   Med.  Assn.,  Jan.  22,    1921.) 


434  DISEASES   OP    CHILDREN 

philia  (e.g.,  in  tetany),  the  wlioop  of  pertussis  may  also  be  due  to 
some  functional  disturbance  in  the  parathyroids,  arising  traumatically 
as  the  result  of  the  harassing  cough  during  the  earlier  stages  of  per- 
tussis. 

These  preparations  do  not  in  the  least  interfere  with  the  action  of 
any  of  the  others  generally  employed,  but  on  the  contrary,  combine 
well  with  them,  as  for  example  in  the  following  mixture : 


Creosoti  Carbonatis                                                         3  i 

4.00 

Syr.  Calcii  et  Natrii  Hypophospliitum                         g  i 

30.00 

Pulv.  et  Mucilaginis  Acaciae                                     q.  s. 

Aquae  Anisi                                                      q.s.ad  f  g  ii 

60.00 

IVI. 

S. — One  teaspoonful  every  four  liours,  for  a   child 

three  years  old. 

My  results  thus  far  have  been  very  encouraging. 

Whenever  necessary  a  small  dose  of  some  morphine  preparation 
with  or  without  2  grains  of  antipyrin  may  be  administered  to  induce 
rest  or  sleep,  and  where  the  heart  is  weak,  a  fresh  infusion  or  the  tinc- 
ture of  digitalis  will  prove  a  grateful  addition.  Numerous  other  reme- 
dies have  been  found  serviceable,  but  caution  is  commended  in  their 
promiscuous  use. 

The  paroxysms  may  frequently  be  controlled  by  pulling  the  lower 
jaw  downward  and  forward.  This  manipulation  is  harmless  and  pain- 
less. Its  application  is  contraindicated  only  in  the  presence  of  food 
in  the  mouth  or  esophagus. 

A  silk  elastic  abdominal  belt  (Kilmer)  is  useful  to  allay  vomiting 
and  the  severity  of  the  paroxysms.  Chloroform  anesthesia  will  some- 
times relieve  the  attacks  almost  magically  and  should  be  tried  in 
desperate  cases,  especially  in  those  associated  with  convulsive  seizures. 

Complications  and  sequelae  arising  should  be  treated  according  to 
indications. 


B     Ext.  Belladonna?  Fl. 

m.  iv 

0.25 

Vini  Ipecacuanha} 

m.  xvi 

1.00 

Nat.  Bromidi 

gr.  xvi 

3.00 

Syr.  Amygdal. 

3iv 

15.00 

Aq.  Destil. 

q.  s.  ad  f  g  ii 

60.00 

M. 

S. — One   teaspoonful  every 

two  to   four  hours,   for 

a  child  two  years  old. 

Whooping'  Cough  in  the  Newborn 

The  following  remarks  are  based  upon  the  observation  of  16  cases 
of  pertussis  in  infants  of  from  nine  to  twenty  days  old.    In  all  of  these 


SPECIFIC   COMMUKICABLE   DISEASES  435 

babies  the  source  of  infection  could  be  traced  to  members  of  the  im- 
mediate family,  although  in  some  of  them  the  positive  history  -was 
not  immediately  apparent.  For  example,  in  one  ease  the  source  of 
infection  was  traced  to  a  grandfather,  sixt^'-four  years  old,  who  for 
a  few  weeks  had  been  sutfering  from  a  paroxysmal  loose  cough  ac- 
companied by  semifainting  spells.  He  had  been  treated  for  cardiac 
asthma.  Six  infants  contracted  the  disease  from  their  mothers  who 
had  been  suffering  from  a  protracted  cough,  supposedly  bronchitis, 
because  of  the  absence  of  the  characteristic  whoop.  As  these  infants 
during  the  first  few  days  after  birth  were  entirely  free  from  any  signs 
of  nasopharyngeal  or  bronchial  catarrh,  there  is  every  reason  to  be- 
lieve that  the  infection  took  place  after  birth,  and,  furthermore,  that 
immunity  was  not  conferred  upon  them  by  their  mothers.  In  the  re- 
maining nine  babies  the  source  of  infection  was  readily  discerned,  since 
one  or  more  members  of  the  family  were  afflicted  with  the  disease. 

The  cases  of  whooping  cough  in  the  newborn  thus  far  recorded  are 
exceptionally  few.  Among  them  may  be  cited  the  classic  cases  of 
Bouchut,  Rilliet,  Barthez,  Currier,  Watson,  Neurath,  and  Holt 
("Twentieth  Century  Encyclopedia"  and  Pfaundler  and  Schloss- 
mann's "Handbook  of  Pediatries").  The  meagerness  of  the  litera- 
ture on  the  subject,  notwithstanding  the  extremely  high  mortality 
which  prevails  among  these  cases,  tends  to  emphasize  the  apparent 
levity  with  which  pertussis  is  looked  upon  even  by  the  profession.  Of 
course,  due  allowance  must  be  made  for  the  fact  that  a  great  many 
infants  succumb  to  the  disease  before  a  correct  diagnosis  has  at  all 
been  arrived  at.  For  be  it  remembered  that  the  symptomatology  of 
pertussis  in  the  newborn  differs  greatly  from  that  observed  in  older 
children.  Whereas  in  the  latter,  as  already  stated,  we  are  usually 
able  to  distinguish  three  characteristic  stages  of  the  disease,  thus, 
stadium  catarrhale,  convulsivum,  and  decrementi,  in  the  newborn  the 
catarrhal  and  paroxysmal  stages  are  confluent,  while  the  catarrhal  stage 
is  so  brief  in  duration  as  entirely  to  escape  observation.  Beginning 
with  occasional  mild  sneezing  or  coughing  a  few  daj^s  after  birth,  it  is 
all  at  once  noticed  that  the  baby  is  struggling  for  air  with  each  fit  of 
coughing,  turns  blue  and  even  black  in  color,  and  after  a  few  expul- 
sive efforts  of  expectoration,  followed  by  gagging  and  trickling  out  of 
frothy  mucus  from  its  mouth,  the  infant  falls  back  pale  and  exhausted, 
in  semicoma  as  it  were.  The  paroxysms  return  at  shorter  or  longer 
intervals,  as  a  rule,  every  five  to  ten  minutes.  The  attacks  of  apnea 
are  almost  invariably  associated  with  temporary  arrest  of  the  heart's 
action,  and  it  is  not  at  all  unusual  for  some  delicate  infants  to  succumb 


436  DISEASES   OF    CHILDREN 

during  a  paroxysm.  I  witnessed  it  in  3  cases — twelve  and  fifteen  days 
old  respectively.  Of  the  remaining  cases  under  my  observation  4  re- 
covered, 7  died  from  bronchopneumonia,  or  rather  hypostatic  or  passive 
pulmonary  congestion,  1  of  cerebral  hemorrhage  and  1  from  inanition. 
One  of  the  cases  of  bronchopneumonia  was  complicated  by  rupture  of 
the  pulmonary  alveoli   (pneumohypoderma,  q.v.). 

The  cerebral  hemorrhage  complicating  pertussis  is  usually  localized, 
giving  rise  to  mono-  or  hemiplegia,  and  when  confronted  with  an  in- 
fant that  has  been  delivered  instrumentally  and  shows  distinct  signs 
of  forceps  traumatism,  the  diagnosis  is  apt  to  be  greatly  obscured.  In 
the  absence  of  a  positive  history  of  whooping-cough,  and  more  espe- 
cially in  the  early  stage  of  the  disease,  it  is  often  also  very  difficult 
to  decide,  whether  or  not  we  are  dealing  with  congenital  heart  disease 
or  hypertrophy  of  the  thymus  gland,  since  in  both  these  affections  more 
or  less  marked  cyanosis  predominates.  In  the  differential  diagnosis 
it  is  well  to  bear  in  mind  that  in  congenital  vitia  cordis,  the  cyanosis 
is  either  permanent  or  becomes  apparent  only  during  fits  of  crying. 
Furthermore,  physical  examination  usually  reveals  definite  signs  of 
heart  disease,  such  as  murmurs  or  pronounced  anatomic  malformations. 
An  enlarged  thymus  sufficiently  marked  to  produce  grave  symptoms 
usually  discloses,  on  percussion,  distinct  dulness  or  flatness  over  the 
upper  portion  of  the  sternum,  particularly  to  the  left  as  low  as  the 
second  rib  and  often  also  to  the  back  between  the  scapulae.  Further- 
more, the  paroxysms  of  asphyxia  in  thymus  hypertrophy  are  much 
less  marked  and  less  frequent  than  in  pertussis.  Mild  cases  of  whoop- 
ing-cough may  sometimes  be  mistaken  for  atelectasis  pulmonum,  but 
this  condition  is  usually  preceded  by  asphyxia  neonatorum  and  is  not 
accompanied  by  sudden  attacks  of  coughing.  Some  aid  in  the  diag- 
nosis may  be  derived  from  a  careful  blood  examination  which  in  per- 
tussis generally  shows  a  pronounced  augmentation  in  the  leucocytes, 
but,  as  there  is  always  a  great  relative  increase  in  the  lymphocytes  in 
the  blood  of  the  newborn,  this  test  is  not  as  decisive  in  infants  as  in 
older  children.  However,  this  test  may  serve  to  detect  the  immediate 
source  of  the  infection  and  should  be  applied  to  the  other  members  of 
the  family  who  happen  to  be  afflicted  with  a  recalcitrant  cough. 

Treatment. — In  view  of  the  extremely  high  mortality  in  pertussis  neo- 
natorum our  main  therapeutic  efforts  must  be  directed  toward  prophy- 
laxis. It  devolves  upon  the  obstetrician  particularly  to  guard  against 
transmission  of  whooping-cough  to  the  newborn,  be  it  by  the  mother 
or  any  other  member  of  the  immediate  family.  Even  if  there  is  only 
a  suspicion,  the  infant  must  be  promptly  isolated,  and  with  further 


SPECIFIC    COMMUNICABLE   DISEASES  437 

corroborative  evidence  of  the  existence  of  the  disease,  immediately 
immunized.  Judging  from  personal  observation,  the  administration  of 
prophylactic  pertussis  vaccine  in  full  doses  is  absolutely  harmless 
even  in  the  youngest  of  infants.  If  the  mother  is  suffering  from 
whooping-cough,  we  must  stop  her  nursing  of  the  infant,  at  least  until 
the  infant  has  been  thoroughly  immunized.  In  a  number  of  cases, 
owing  to  the  frequency  and  severity  of  the  paroxysms,  the  infants 
are  totally  unable  to  nurse  at  the  breast,  in  which  event  it  will  be 
found  advantageous  to  feed  them  on  the  breast  milk  by  means  of 
Breck's  feeding  tube,  in  small  quantities,  and  at  short  intervals,  in 
the  same  manner  as  practiced  with  premature  babies.  The  active 
treatment  is  very  unpromising.  In  6  of  my  cases  pertussis  vaccine 
as  a  therapeutic  agent  proved  useless.  Some  benefit  may  be  derived 
from  the  early  administration  of  bromides  and  lime  and  soda  hypophos- 
phites  (see  pp.  433,  434)  to  arrest  the  frequency  of  the  spasms;  of  ipe- 
cacuanha, to  facilitate  expectoration  and  thus  to  hasten  the  termination 
of  the  paroxysms,  and  of  strophanthus,  to  sustain  the  baby's  heart 
action.  The  bromides,  either  potassium  or  sodium,  should  be  given 
in  sufficiently  large  doses  to  induce  more  or  less  profound  sleep.  One 
grain  every  three  to  six  hours  in  the  beginning  and  less  frequently 
thereafter  usually  answers  the  purpose.  The  ipecac,  preferably  the 
syrup,  should  be  given  in  from  3  to  5  minim  doses  until  the  cough 
has  thoroughly  loosened,  and  whenever  the  chest  and  throat  become 
choked  up  by  the  tenacious  mucus,  it  is  occasionally  of  advantage  to 
increase  the  dose  of  the  ipecac  sufficiently  to  produce  emesis.  Vom- 
iting, by  the  way,  is  Nature's  method  of  relieving  the  paroxysms 
of  pertussis.  The  dosage  of  the  tincture  of  strophanthus  should 
vary  with  the  condition  of  the  infant's  heart.  Generally,  Y2  to  1 
minim,  three  times  a  day,  will  be  found  sufficient.  Finally,  it  is  most 
important  to  remember  that  an  abundance  of  fresh  air  is  the  sine  qua 
non  in  whooping-cough,  and  that,  especially  in  delicate  babies,  oxygen 
by  inhalation  is  worthy  of  trial. 

TUBERCULOSIS 

Introductory  Remarks 

(Prevention  of  Tuberculosis) 

Without  denying  the  possibility  of  antenatal  direct  bacillary  trans- 
•  mission  of  tuberculous  disease  from  parents  to  offspring   (six  cases  of 
undoubted  fetal  tuberculosis  are  on  record),  it  may  be  set  down  as  ab- 
solutely certain  that,  with  but  very  few  exceptions,  tuberculosis  in  in- 


438  DISEASES    OF    CHILDREN 

fancy  and  childhood,  as  in  adolescence,  is  acquired  as  a  result  of  post- 
natal* infection  by  the  tubercle  bacillus  of  Koch.  The  bacillus  invades 
the  human  organism  principally  through  the  respiratory  (by  inhala- 
tion in  about  80  per  cent)  and  alimentary  tracts  (by  ingestion  in  about 
15  per  cent,  often  by  swallowing  tuberculous  material  derived  from  the 
lungs)  ;  less  frequently  through  the  skin  or  mucous  membranes  (slight 
traumatism,  skin  eruptions,  etc.),  and  occasionally  also  through  the 
blood,  when  broken  down  tuberculous  foci  are  carried  into  the  circu- 
lation. The  readiness  with  which  infection  occurs  depends  chiefly  upon 
the  power  of  resistance  of  the  patient  and  the  environment  in  which 
the  patient  is  forced  to  live.  This  explains  the  greater  frequency  of 
tuberculous  disease  in  children  of  tuberculous  parentage.  An  under- 
mined constitution  from  one  cause  or  another  (most  particularly  acute 
infectious  diseases,  such  as  measles,  whooping-cough  or  influenza)  forms 
an  easy  prey  to  the  tuberculous  germ  and,  varying  with  the  primary 
seat  of  the  infection,  the  natural  recuperative  strength  of  the  tissues 
involved,  and  the  therapeutic  measures  adopted  to  resist  and  combat 
further  systemic  invasion,  tuberculous  disease  may  remain  localized  or 
become  general,  and  pursue  an  acute  or  chronic  course. 

The  successful  management  of  tuberculosis  rests  upon  a  thorough  ap- 
preciation of  the  aforementioned  facts.  We  possess  no  specific  remedy 
against  tuberculosis,  once  fully  established,  but  the  disease  is  certainly 
preventable  and  in  its  incipient  stage  curable — a  great  deal  more  than 
can  be  said  of  a  number  of  nontuberculous,  organic  affections. 

Prevention  of  tuberculosis  in  a  child  must  begin  immediately  after 
its  birth.  Every  infant  should  be  removed  from  a  tuberculous  envi- 
ronment !  The  air  the  infant  is  to  breathe  should  be  pure,  the  room  it  is 
kept  in  sanitary  and  well  ventilated,  though  warm  enough  to  suit  its 
needs.  From  earliest  infancy  the  child  should  be  gradually  accus- 
tomed to  outdoor  air,  and,  as  he  grows  older,  he  should  spend  most  of 
the  day  outdoors,  except  when  the  weather  is  particularly  bad.    In  this 


*In  988  children  examined  by  von  Pirquet  the  reaction  was  found  positive: 

0  to   3   months    0  per  cent       4   to    6   years    50  per  cent 

3  to   6  months    5  per  cent       6  to   10  years    57  per  cent 

6  to   12   months    16  per  cent       10   to    14   years    68  per  cent 

1  to   2   years    24  per  cent 

Bass  and  Hess,  Jour.  A.  M.  A.,  Jan.   11,   1919,  made  the   following  observations: 

AGE   DISTRIBUTION   OF   PATIENTS   REACTING   POSITIVELY   TO    CUTANEOUS    OR    INTRACUTANEOUS    TEST 


AGE 

NUMBER 
TESTED 

REACTING 

POSITIVELY 

NUMBER 

PER     CENT 

0-6    months    

51 
38 

29 
45 
28 

4 

6 

S 

14 

12 

7  8 

6-12    months    

15  8 

1  -2    years    

17  2 

2-3    vears 

31.1 

3-S    years    

42.8 

SPECIFIC    COMMUNICABLE   DISEASES 


439 


event  he  should  remain  well  dressed  in  front  of  an  open  window.  Spe- 
cial attention  should  be  paid"  to  his  breatliing.  Any  obstruction  to  free 
nasal  breathing,  be  it  adenoids,  hypertrophy  of  the  tonsils,  or  of  the 
nasal  mucous  membrane,  or  deformity  of  the  nasal  bones,  should  be 
treated  or  removed  without  delay.  The  child  should  be  taught  to  breathe 
deeply — few  children  know  how  to  breathe,  as  is  readily  evinced  in  ex- 
amining a  child's  chest.  Infants  should  be  encouraged  to  cry  off  and 
on,  and  older  children  to  recite  and  sing  in  the  open  air.    As  the  child 


Fig.  99. 


Fig.  100. 


Fig.  101. 


,('  <j;-;,  \ 


Fig.  102.  Fig.  103. 

Figs.  99-103. — Breathing  exercises. 

grows  old   enough   intelligently   to   follow   instructions,   he   should   be 
taught  the  following  breathing  exercises: 

1.  Deep  inhalation,  while  raising  the  arms  to  a  horizontal  jiosition ; 
slow  exhalation,  bringing  the  arms  down  (Pig.  99). 

2.  Deep  inhalation  with  the  arms  placed  lightly  upon  the  front  of 
the  lower  portion  of  the  chest ;  slow  exhalation,  bringing  the  arms  down 
(Fig.  100). 

3.  Deep  inhalation,  while  bringing  the  arms  first  to  a  horizontal  posi- 
tion, then  above  the  head,  and  lastly — while  still  holding  the  breath — 


440  DISEASES    OP    CHILDREN 

bending  the  upper  body  backward;  slow  exhalation,  while  lowering  the 
arms  sideways  (Fig.  101). 

4.  Deep  inhalation,  while  bringing  the  hands  together  in  front  of 
the  abdomen,  and  from  here  slowly  along  the  thorax  and  chin  above 
the  head  and  as  far  as  possible  back  of  it ;  slow  exhalation,  bringing  the 
hands  down  to  the  original  position  (Fig.  102). 

5.  Deep  inhalation,  while  bending  the  upper  body  as  far  back  as  pos- 
sible, with  the  hands  fixed  on  the  hips;  slow  exhalation,  while  resuming 
original  position  (Fig.  103). 

During  the  breathing  exercises  the  child  assumes  the  position  of  mili- 
tary "attention."  lie  breathes  with  the  mouth  closed,  occupying  about 
four  seconds  for  inhalation,  four  seconds  for  retention  of  the  air  and 
three  seconds  for  exhalation.  The  exercises  should  be  practiced  either 
outdoors  or  in  front  of  an  open  window ;  at  first  four  or  five  times  a 
day,  but,  after  the  child  gets  accustomed  to  expand  his  chest  properly 
during  the  respiratory  act,  only  once  or  twice  a  day  or  not  at  all.  The 
breathing  exercises,  like  any  other  physical  work,  should  not  be 
overdone,  and  never  continued  too  long  as  to  become  tiring.  As  pro- 
longed holding  of  the  breath  interferes  with  the  normal  heart's  action, 
it  is  contraindicated  in  organic  heart  disease.  Short-distance  running, 
and  peaceful  outdoor  games  (hand-ball,  basket-ball,  and  tennis)  also  are 
helpful  to  expand  the  lungs.  The  principal  benefit  derived  from  these 
breathing  exercises  is  the  purification  of  the  lung  tissue  by  the  free  in- 
flow and  uniform  distribution  of  oxygen,  thus  preventing  pulmonary 
congestion  which  acts  as  a  predisposing  cause  of  tuberculous  infection. 

What  pure  air  does  for  the  prevention  of  pulmonary  tuberculosis, 
suitable  feeding  from  birth  will  do  for  the  prevention  of  tuberculosis 
of  the  alimentary  tract.  It  is  highly  essential  ever  to  bear  in  mind  that 
tubercle  bacilli  rarely,  if  ever,  survive  the  action  of  normal  digestive 
juices.  The  gastroenteric  tract,  especially  the  stomach,  therefore,  should 
be  spared  pathologic  alteration.  Breast  milk  of  a  healthy  mother  or 
wet-nurse  should  at  all  times  be  the  food  of  choice  for  an  infant  up  to 
nine  months  old.  With  increasing  age  the  dietary  should  undergo  a 
gradual  change,  always  selecting,  however,  such  articles  of  food  as  will 
best  accomplish  the  object  in  view,  i.  e.,  ample  nutrition  for  the  growth 
and  development  of  the  child  with  least  possible  injury  to  the  digestive 
organs.  Overfeeding  especially  is  to  be  avoided.  It  goes  without  saying 
that  contaminated  food  should  never  form  a  part  of  the  dietary.  Cow's 
milk  of  doubtful  purity  should  be  sterilized,  and  other  articles  of  food 
of  such  character  boiled.  The  teeth  should  receive  special  attention, 
since  cavities  of  decayed  teeth  not  rarely  harbor  tubercle  bacilli  and 


SPECIFIC    COMMUNICABLE   DISEASES  441 

early  loss  of  the  permanent  teeth  forms  one  of  the  principal  causes  of 
acute  and  chronic  dyspepsia — as  a  result  of  insufficient  mastication  of 
the  food — and  indirectly  enhances  the  development  of  tuberculosis. 
Children  should  be  taught  to  eat  slowly,  and  to  refrain  from  eating  be- 
tween meals. 

Tuberculous  infection  through  the  skin  and  contiguous  mucous  mem- 
branes should  be  guarded  against  by  scrupulous  cleanliness  of  these 
structures,  avoidance  of  external  injury  and  skin  eruptions,  and  by  im- 
mediate treatment  of  open  wounds  and  all  such  skin  lesions  as  are  asso- 
ciated with  itching  and  compel  scratching.  Those  intrusted  with  the 
care  of  babies  and  older  children  should  be  instructed  to  give  their 
charges  a  tub  bath  in  the  evening  and  a  sponge  bath  in  the  morning 
followed  by  gentle  rubbing  of  the  entire  body.  Of  course,  the  bathing 
should  include  careful  cleansing  of  the  nails,  which  should  be  kept 
clipped  short,  of  the  ears,  of  the  nose  and  scalp,  and,  in  older  children, 
also  of  the  teeth.  From  earliest  infancy  children  should  very  gradually 
get  accustomed  to  cool  sponge  baths.  At  first  the  infant  may  be  given 
a  cool  alcohol  sponge  bath,  and  after  toleration  has  been  established 
the  alcohol  should  gradually  be  replaced  by  water,  and  finally  by  full 
cool  tub  or  shower  baths  (except  during  cold  winter  months).  The 
advisability  of  cleansing  the  infant's  mouth  is  still  a  matter  of  opinion. 
I  am  inclined  to  favor  gentle  wiping  of  the  infant's  mouth  twice  daily 
with  a  cotton  swab  dipped  in  sterile  water.  Older  children  should  be 
taught  the  use  of  a  soft  brush  for  the  teeth  and  an  antiseptic  gargle 
for  the  mouth  and  throat.  The  importance  of  early  removal  of  naso- 
pharyngeal obstruction  to  breathing  has  already  been  alluded  to.  This 
question  cannot  too  strongly  be  emphasized,  for  the  adenoid  tissue,  in 
addition  to  interfering  with  free  respiration,  is  surely  one  of  the  most 
rampant  sources  of  tuberculous  infection.  Skin  eruptions  should  at 
once  be  combated.  This  refers  especially  to  running  sores  from  what- 
ever cause,  and  to  all  skin  diseases  which  sooner  or  later  lead  to  mac- 
eration and  denudation  of  the  skin.  Intertrigo  in  infants  is  best  pre- 
vented by  frequent  changing  of  the  diapers  and  keeping  the  buttocks 
perfectly  clean  and  dry.  The  child  should  be  kept  from  scratching  the 
affected  portions  of  the  skin  by  immediate  application  of  antipruritic 
drugs  and  by  restraining  the  child's  hands  by  means  of  one  of  the  many 
useful  contrivances.  Open  wounds  should  be  dressed  antiseptically  un- 
til healed.  Vaccination  wounds  especially  should  receive  careful  at- 
tention. Certain,  though  it  be,  that  latent  tuberculosis  is  occasionally 
lighted  up  through  vacinnation,  and  that  tuberculosis  has  in  very  ex- 
ceptional instances  been  traced  to  vaccine  infected  by  tubercle  bacilli, 


442 


DISEASES    OP    CHILDREN 


it  is  absolutely  settled  that  the  great  majority  of  cases  of  tuberculosis 
following  vaccination  are  the  result  of  direct  bacillary  infection  through 
an  unprotected  vaccination  wound. 

Effective  as  these  local  measures  are  in  the  prevention  of  tuberculosis, 
their  efficiency  is  very  insignificant  as  compared  with  the  natural  de- 
fensive resources  of  a  healthy  constitution.  Our  aim,  therefore,  should 
be  directed  chiefly,  from  earliest  infancy,  to  rendering  the  patient,  so  to 
say,  immune  against  tuberculosis.  This  is  best  accomplished  by  outdoor 
life,  wholesome  nutrition,  and  sanitary  environment.  Those  showing 
a  tendency  to  remain  delicate  in  health  should  reside  in  the  country. 

Miliary  Tuberculosis 

(Hasty  Consumption) 
This  disease  is  characterized  by  wide  distribution  of  the  tuberculous 
lesions.     The  latter  are  from  a  pinhead  to  a  millet  seed  in  size,  gray 


Fig.  104. — Acute  pulmonary  miliary  tuberculosis  (cut  surface  of  the  lung),  a. 
So-called  obsolete  tubercle  (old  encapsulated  caseous  focus),  b.  Induration,  c. 
Caseous,  partly  agminated  nodules  (transverse  section  of  caseous  bronchi),  d.  Sub- 
miliary  noncaseatcd  tubercle  in  the  true  lung  tissue,  e.  Tubercle  of  the  pulmonary 
pleura.    One-half  natural  size.     (Langerhans  and  Brooks,  F.  A.  Davis  Co.) 


SPECIFIC    COMMUNICABLE   DISEASES 


443 


or  yellow  in  color,  and  firm  in  consistence.  They  are  fonnd  scattered 
thronghout  almost  all  the  organs  and  tissues  of  the  body,  but  especially 
the  lungs  and  bronchial  glands,  intestines  and  mesenteric  glands,  the 
liver,  spleen,  kidneys  and  bladder,  and  the  brain  and  its  coverings. 
They  may  remain  latent  for  some  time,  or  give  rise  to  indefinite  symp- 
toms, such  as  anorexia,  dyspepsia,  gastroenteritis,  and  emaciation,  or 
symptoms  of  pulmonary  phthisis.  The  outbreak  is  often  determined  by 
some  intercurrent  disease  or  traumatism,  but  once  established  it  usually 
runs  a  very  violent  course. 


Fig.   105. — Miliary  tuberculosis  of  the   lungs  in  a  child  nine  years  old. 

The  temperature  rises,  is  intermittent,  hectic  in  character,  only  rarely 
drops  to  normal,  and  may  be  associated  with  chills  and  sweats.  In  the 
beginning,  especially  in  the  absence  of  marked  pulmonary  sj^mptoms, 
and  in  the  presence  of  a  large  liver  or  spleen,  or  both,  the  disease  greatly 
resembles  malarial  fever  or  typhoid.  Careful  examination,  however, 
reveals  the  absence  of  the  malarial  or  typhoidal  germs  in  the  blood. 
Where  signs  of  pulmonary  disease  predominate,  it  is  readily  confounded 
with  lobular  pneumonia.  In  such  cases  the  diagnosis  is  extremely  diffi- 
cult and  often  can  be  decided  only  by  microscopic  examination  of  the 


444  DISEASES    OF    CHILDREN 

sputum  (frequently  negative)  and  the  tuberculin  test.  As  the  disease 
advances  the  diagnosis  may  be  based  upon  the  extreme  emaciation,  mul- 
tifariousness of  the  S3'mptomatology,  the  violence  and  persistence  of  the 
febrile  attacks  and  x-ray  examination. 

The  symptoms  and  course  of  the  disease  differ  with  the  seat  of  the 
lesions.  The  lungs  almost  invariably  show  signs  of  consolidation  (dul- 
ness,  crepitant  rales,  dyspnea,  cyanosis,  short  cough),  and  the  intes- 
tines rarely  escape  involvement.  In  some  cases  brain  symptoms  (ap- 
athy, jactitations,  stupor,  localized  convulsions,  tubercles  in  the  choroid, 
etc.,  up  to  a  typical  picture  of  meningitis)  predominate;  in  others 
again,  symptoms  of  disturbed  circulation  (marked  cyanosis,  edema, 
rapid  feeble  pulse,  anemia  and  exhaustion,  etc.)  prevail.  The  latter 
phenomena  usually  precede  the  fatal  issue,  which  generally  occurs 
within  from  four  to  eight  weeks.  Cases  running  a  subacute  course  may 
last  a  few  weeks  or  months  longer,  are  not  rately  erroneously  diagnosed 
and  treated  as  marasmus,  their  true  nature  not  being  detected  until 
postmortem.  It  is  in  those  cases,  particularly,  that  the  von  Pirquet 
or  intracutaneous  reactions, and  a  roentgenogram  are  so  helpful  in  the 
diagnosis,  and  should  always  be  resorted  to  early.  Then  and  then  only 
may  our  efforts  to  arrest  or  possibly  cure  the  disease  prove  successful. 

For  details  of  treatment,  see  p.  449. 

Phthisis  Pulmonum 

(Tuberculosis  of  the  Lungs  and  Bronchial  Glands) 

The  lungs  proper,  the  bronchial  glands,  or  both,  may  be  the  pri- 
mary seat  of  tuberculous  deposits.  The  upper  lobes  are  more  frequently 
affected  than  the  lower,  and  the  portions  adjacent  to  the  bronchial 
glands  more  so  than  the  remaining  parts.  The  pathologic  changes  con- 
sist essentially  in  the  formation  of  variously  sized  caseous  nodules  filled 
with  colonies  of  tubercle  bacilli  and  large  so-called  giant  cells,  and  sub- 
sequent softening  and  breaking  down  of  the  nodules,  forming  cavities 
which  may  vary  in  size  from  a  pea  to  a  walnut,  or  larger.  There  is  usu- 
ally an  endarthritis  with  miliary  tubercles  in  the  walls  of  the  blood  ves- 
sels. The  pleura  is  thickened  and  the  lining  of  the  larynx,  trachea  and 
bronchi  ulcerated.  In  some  cases,  especially  in  those  receiving  early 
and  suitable  treatment,  the  tuberculous  process  is  arrested  by  encap- 
sulation of  the  necrosed  structures  by  newly  formed  connective  tissue, 
leading  to  contraction  and  formation  of  a  firm  cicatrix.  In  this  event 
the  enclosed  masses  are  in  part  absorbed,  and  in  part  calcified.  The  tu- 
berculous affection  of  the  bronchial  glands  also  consists  in  hyperplasia 
and  caseous  degeneration.     This  process  usually   (sooner  or  later)   ex- 


SPECIFIC    COMMUNICABLE   DISEASES 


445 


^      '^^ 


Fig.  106. — Tuberculosis,  Horizontal  sec- 
tion through  the  tuberculous  lower  lobe  of 
the  right  lung  of  a  two-year-old  child,  (a) 
caseous  focus  in  the  region  of  the  anterior 
border;  (6)  nontuberculous  posterior  bor- 
der; (c)  transverse  section  of  bronchus; 
(d,  ^)  easeated  lymph  glands;  (e)  pul- 
monary vein;  (/)  point  of  adhesion  of  the 
vein  e  with  the  lymph  gland  d^;  (g) 
tubercle  in  the  lymph  vessels  of  the  lung 
parenchyma;  (h)  periarterial,  (t)  peribronchial,  (fc)  perivenous  tubercles;  (I) 
lymph-vessel  tubercles  of  the  pleura;  (m)  tubercle  in  the  connective  tissue  of  the 
hilus  of  the  lung.     X  ^-     (Ziegler.) 


446  DISEASES   OF    CHILDREN 

tends  to  tlie  contiguous  structures,  exerts  pressure  upon  tlic  adjacent 
blood  vessels,  nerves,  and  bronchi,  and,  after  forming  adhesions,  may 
displace,  erode  and  perforate  these  parts.  In  this  manner  not  only  may 
tuberculous  infection  be  rapidly  carried  throughout  the  lungs  and  more 
distant  organs  (producing  an  acute  or  chronic  tuberculous  pneumonia), 
but  perforation  of  a  blood  vessel  or  bronchus,  or  entrance  of  caseous 
masses  into  the  trachea  may  unexpectedly  produce  sudden  and  often 
fatal  hemorrhage  or  suffocation. 

The  symptoms  vary  with  the  primary  seat  of  the  lesion  and  the  sub- 
sequent pathologic  changes.  A  small  tuberculous  focus,  be  it  in  the 
lung  or  bronchial  glands,*  rarely  gives  rise  to  any  definite  clinical  phe- 
nomena. As  a  rule,  in  the  beginning  the  disease  pursues  a  latent  course. 
This  is  especially  true  in  infants.  The  child  is  pale,  loses  in  weight, 
often  notwithstanding  good  appetite,  gets  tired  on  the  slightest  exer- 
tion, "hems"  and  coughs  a  little,  and  the  temperature  rises  somewhat 
in  the  evening.  Sooner  or  later  the  symptoms  become  more  distinct. 
Emaciation,  cough,  and  gastrointestinal  disturbances  increase  in  se- 
verity; the  child  suffers  from  dyspnea,  and,  if  the  bronchial  glands  are 
involved,  from  paroxysmal  attacks  of  coughing,  greatly  resembling  per- 
tussis (the  cough  has  a  metallic  timber  with  a  characteristic  expira- 
tory whoop).  This  cough  is  the  result  of  pressure  exerted  by  the  en- 
larged bronchial  glands  upon  the  pneumogastric  and  recurrent  nerves. 
Physical  signs,  however,  are  often  still  wanting.  Occasionally,  percus- 
sion over  the  mediastinum  may  reveal  increased  dulness,  but  in  infants 
this  symptom  is  not  pathognomonic  in  view  of  the  physiologically  large 
thymus.  Indeed,  the  disease  is  often  not  detected  until  grave,  not  rarely 
fatal,  symptoms  (e.g.,  hemoptysis,  hectic  fever)  announce  the  serious- 
ness of  the  condition.  The  diagnosis  of  pulmonary  phthisis  in  infants, 
therefore,  must  be  based  upon  the  entire  clinical  picture,  rather  than 
the  local  symptoms.  If,  for  example,  bronchial  catarrh  is  associated 
with  progressive  emaciation,  multiple  glandular  swellings,  protracted 
diarrhea  and  possibly  also  some  bone  or  joint  disease,  the  diagnosis  of 
tuberculosis  is  justifiable,  even  though  careful  examination  of  the  thorax 
fails  to  reveal  pulmonary  consolidation  or  cavity.  For  corroborative 
evidence  we  should  carefully  examine  the  child's  sputum  (obtained  by 
means  of  a  catheter  introduced  to  the  base  of  the  tongue)  for  tubercle 
bacilli,  and  employ  the  tuberculin  and  complement-fixation  tests  and  the 
Roentgen-ray. 

In  older  children  the  symptomatology  of  pulmonary  tuberculosis  is 
essentially  the  same  as  in  adults.     Its  onset  is  usually  insidious,  and 


•According  to   D'Espine,   bronchophony   heard   along  the   spinal   column   below  the   second   or 
third  dorsal  vertebra  points  strongly  towards  enlargement  of  the  bronchial  lymph  nodes. 


SPECIFIC    COMMUNICABLE   DISEASES 


447 


quite  frequently  follows  delayed  convalescence  from  some  acute  disease, 
such  as  pertussis,  morbilli,  broncho-  or  lobar  pneumonia,  and  the  like. 
The  child  fails  fully  to  recuperate,  is  pale,  thin,  and  feeble,  suffers  from 
slight  shortness  of  breath,  dry  cough,  chilliness  and  fever.  At  first 
these  symptoms  are  more  or  less  masked,  but  as  the  lung  destruction  ad- 
vances the  symptoms  and  physical  signs  grow  rapidly  worse.  The  cough 
becomes  persistent,  often  distressing,  especially  at  night,  and  attended 
by  expectoration  and  pain.  The  fever  is  intermittent  or  remittent  (hec- 
tic) in  character.  It  is  usually  normal  or  slightly  above  normal  in 
the  morning,  and  from  two  to  three  degrees  higher  in  the  evening.  It 
is  often  preceded  by  chilliness  and  followed  by  profuse  sweating.  Dur- 
ing the  height  of  the  fever  the  cheeks  are  usually  brightly  flushed  and 


Fig.   107. — Phthisis  pulmonum  in  a  child  twenty  months  old. 


contrast  strongly  with  the  remaining  portions  of  the  face  which  are 
deathly  pale.  Night  sweats  are  often  observed  early  in  the  course  of 
the  disease.  With  further  progress  of  the  disease  the  expectoration 
becomes  mucopurulent  or  purulent,  nummular,  and  streaked  with 
blood;  the  fever  more  irregular,  and  attended  by  great  exhaustion,  and 
the  emaciation  profound. 

The  agony  may  be  further  aggravated  by  the  concurrence  of  a  num- 
ber of  painful  complications.  The  disease  may  extend  to  the  pleura 
(pleuritis  sicca  or  with  serous  or  hemorrhagic  effusion)  ;  to  the  trachea 
and  larynx  (dysphagia,  frequent  hemorrhages,  and  aphonia)  ;  to  the 
alimentary  tract  (colliquative  diarrhea);  and  where  the  bronchial 
glands  or  pleura  are  involved,  to  the  pericardium   (pericarditis).     By 


448  DISEASES   OF    CHILDREN 

this  time,  and  sometimes  at  an  earlier  period  the  child  presents  a  char- 
acteristic, ghastly  appearance.  The  cheeks  are  hollow,  the  eyes  and 
temples  sunken,  the  bones  of  the  face  and  the  ears  prominent,  the  nose 
is  pointed  and  drawn,  and  the  hair  thinned,  lusterless  and  brittle.  The 
face  is  either  deathly  pale  or  marked  by  florid  redness  along  the  zygo- 
matic regions.  The  neck  is  wasted,  the  supra-  and  subclavicular  spaces 
are  depressed,  the  shoulders  stoop,  and  the  shoulder  blades  project 
wing-like  far  beyond  the  shrunken,  immovable  spine.  The  thorax  is 
narrow  and  contracted,  and  the  ribs  overlap  each  other,  effacing  the 
intercostal  spaces.  The  abdomen  is  flat  or  deeply  sunken  below  the 
strikingly  prominent  pelvic  bones.  The  extremities  are  mere  skin  and 
bone  and  their  epiphyseal  ends  seem  greatly  enlarged  as  they  protrude 
through  the  wasted,  arid  integument. 

The  physical  signs  vary  with  the  stage,  location  and  extent  of  the 
lesions.  As  already  mentioned  tuberculosis  of  the  bronchial  glands 
may  by  physical  examination  entirely  escape  observation.  The  same 
holds  true  of  cases  where  the  tubercles  are  scattered  throughout  the 
lungs  and  do  not  coalesce.  On  the  other  hand,  where  pulmonary  con- 
solidation (tuberculous  pneumonia)  occurs  early  and  progresses  rap- 
idly, the  physical  signs  resemble  those  of  ordinary  pneumonia,  i.  e.,  dul- 
ness  on  percussion,  prolonged  expiration,  increased  vocal  fremitus,  fine, 
coarse  and  crepitant  rales,  and  bronchial  breathing.  To  these  may  be 
added  the  physical  signs  of  dry  or  serohemorrhagic  pleurisy  (see  p. 
330),  which  frequently  accompanies  phthisis  pulmonalis.  Where  cav- 
ities are  formed,  the  physical  signs  consist  of  cavernous  respiration, 
bronchophony  or  pectoriloquy.  The  percussion  resonance  is  amphoric, 
if  the  walls  around  the  cavity  are  thin  and  tense ;  cracked-pot  sound,  if 
the  walls  are  thin  and  relaxed,  and  dull,  if  the  walls  are  thick.  If  pneu- 
mothorax is  present,  the  percussion  sound  in  tympanitic,  and  the  respir- 
atory murmur  is  lost;  while  hydropneumothorax  gives  rise  to  tympan- 
itic resonance  above  the  water  line,  dulness  below,  and  metallic  tink- 
ling on  auscultation. 

The  poignancy  of  the  clinical  picture  just  depicted  notwithstanding, 
errors  of  diagnosis  are  quite  possible.  Pulmonary  phthisis  may  readily 
be  confounded  with  bronchial  dilatation,  localized  empyema,  fetid 
bronchitis,  pulmonary  gangrene,  and  syphilis.  In  view  of  the  prognos- 
tic importance  of  an  early  diagnosis  of  tuberculosis,  it  is  imperative  to 
employ  every  means  of  diagnosis  (especially  repeated  examination  of 
the  sputum,  the  tuberculin  reaction  and  the  x-ray)  to  clear  up  all  doubt. 

The  course  and  duration  of  phthisis  pulmonum  ranges  within  very 
wide  limits.    Not  only  is  it  true  that  tuberculosis  may  proceed  a  latent 


SPECIFIC    COMMUNICABLE   DISEASES  449 

course  for  months  or  years  and  suddenly  break  out — often  after  some 
trivial  cause,  such  as  vaccination,  measles,  etc.— and  rapidly  end  fa- 
talh'  under  symptoms  of  lobular  or  lobar  pneumonia  and  the  like,  but 
postmorten  examinations  have  repeatedly  established  the  fact  that  after 
existing  for  some  time,  with  or  without  indications  of  their  presence, 
tuberculous  lesions  may  heal  spontaneously  never  to  return.  As  a  rule, 
however,  pulmonary  phthisis  in  young  children  runs  quite  an  acute 
course.  Unless  the  disease  is  arrested  in  its  incipiency,  infants  usually 
succumb  to  it  Avithin  from  four  to  eight  weeks  either  from  the  imme- 
diate effects  of  the  pulmonary  lesions,  or  as  a  result  of  generalized  tu- 
berculosis not  rarely  of  the  miliary  variety.  In  older  children  the  dis- 
ease pursues  a  less  violent  course,  and,  as  in  adults,  shows  a  tendency 
to  remain  localized  at  its  originally  infected  focus  until  a  very  late  stage 
of  the  disease.  If  the  tuberculous  process  is  allowed  to  continue,  death 
invariably  occurs  in  from  two  to  three  years  or  earlier — either  from 
asthenia  (with  symptoms  of  gradual  exhaustion,  profound  anemia, 
dropsy,  etc.)  or  from  apnea  (suffocation  by  sudden  hemorrhage,  rup- 
ture of  large  cavity,  pulmonary  edema,  etc.).  On  the  other  hand,  if  the 
tuberculous  process  is  detected  in  its  incipiency — which  is  quite  possi- 
ble with  the  existing  modern  diagnostic  methods,  more  especially  the 
tuberculin  tests  and  x-ray— and  immediately  and  energetically  treated, 
the  chances  for  arrest  and  eventual  cure  of  consumption  of  the  lungs 
are  very  good  indeed. 

Treatment.- — The  treatment  comprises  outdoor  life,  good  food,  per- 
sonal hygiene,  and  symptomatic  medication.  Whenever  possible,  tu- 
berculous children  should  be  sent  to  the  country  regions  where  the 
climate  is  dry  and  of  equable  temperature,  so  as  to  allow  the  pa- 
tients to  enjoy  outdoor  air  the  greater  part  of  the  day.  The  climates 
of  New  Mexico,  Arizona,  and  Egypt  are  best  suited  for  the  purpose,  al- 
though a  great  many  patients  will  be  found  to  do  well  in  Colorado, 
in  the  Adirondacks  and  Sullivan  County  of  New  York,  in  Montana, 
Wyoming  and  North  Carolina.  Those  financially  incapacitated  to 
take  advantage  of  these  climates  should  be  removed  to  climatically 
less  favorable  mountain  regions  or  even  to  ordinary  city  suburbs,  but 
at  all  events  should  not  be  left  to  perish  in  overcrowded,  unsanitary 
tenement  districts.  It  is  often  of  great  advantage  to  place  the  child 
in  an  up-to-date  sanatorium  (if  possible  in  a  private  room)  since 
prophylactic  and  active  therapeutic  measures  are  more  accurately 
enforced  (and  with  less  resistance  on  the  part  of  the  patient)  under 
the  supervision  of  a  reliable  physician  and  nurse  of  a  properly  con- 


450 


DISEASES   OP   CHILDREN 


SPECIFIC    C0MMUNICABLl/-]5l$iEliSBS^.  r  -        .451 

ducted  sanatorium,  than  at  the  patient's  residence  among  his  timid 
and  sympathetic  immediate  relatives. 

The  diet  should  vary  with  the  age  of  the  patient,  but  should  be 
highly  nutritious  and  liberal.  Milk,  meat,  eggs,  fresh  fish,  oatmeal, 
peas,  beans  and  lentils,  carrots,  spinach,  asparagus,  potatoes,  etc.,  in 
addition  to  an  ample  supply  of  bread  and  butter,  should  form  the  prin- 
cipal components  of  the  regular  meals.  Between  meals  the  child 
should  receive  plenty  of  fresh  fruit  or  fruit  juices,  and,  to  satisfy 
its  craving  for  condiments,  a  moderate  supply  of  sugar,  sweet  or  milk- 
chocolate  or  calf's  foot  jelly,  and  the  like. 

The  room  occupied  by  the  patient  should  be  large  and  airy,  and  its 
windows  open  day  and  night,  irrespective  of  season  or  weather.  The 
child  should  sleep  alone.  In  addition  to  a  warm  cleansing  soap  bath 
once  a  w^eek,  it  should  receive  a  cool  sponge  bath  twice  a  day  fol- 
lowed by  brisk  rubbing  of  the  entire  body.  The  underwear  should  be 
of  thin  silk  or  wool,  and  the  outer  garments  should  vary  with  the 
season  of  the  year — always  sufficient  to  keep  the  patient  comfortably 
warm.  In  the  absence  of  fever  or  circulatory  disturbance,  light 
exercise  that  does  not  fatigue  acts  very  beneficially.  Horseback  rid- 
ing is  highly  to  be  recommended. 

The  value  of  drugs  as  auxiliaries  in  the  successful  management  of 
pulmonary  tuberculosis  should  not  be  underestimated.  It  is  not  very 
long  ago  that  creosote  was  almost  universally  hailed  as  the  specific 
against  consumption.  And,  while  its  curative  claims  had  been  (as 
is  always  being  done  with  new  methods  of  treatment)  grossly  exag- 
gerated,* its  efficiency  to  relieve  distressing  symptoms  (useless  cough) 
and  to  aid  in  arresting  the  further  spread  of  the  tuberculous  lesion 
cannot  wholly  be  denied.  Creosote  should  be  given  in  small  grad- 
ually increased  doses,  well  diluted  in  milk,  malt  extract  or  red  wine. 
The  hypophosphites  also  are  deserving  of  trial,  and  may  advanta- 
geously be  combined  with  malt  and  cod  liver  oil,  as  follows : 


IJ     Olei  Morrhuae                                        3  iv 

120.00 

Extr.  Malti                                              gi 

30.00 

Syr.  Hypophosph.  Comp.                     g  i 

30.00 

Glycerini                                                   3  iv 

1.5.00 

Pulveris  Acaciae                                    3  iv 

15.00 

Aq.  Cinnamomi                      q.s.  ad  f  §  viii 

240.00 

M. 

S. — Two  teaspoonfuls  three  times  a  day. 

*Most  recently  Chaulmoogra  oil   has  been  brought  to  the   front  as  an  efficient  antituberculosis 
remedy   (Editorial  Jour.   Am.   Med.   Assn.,   Ixxiv,  No.   23,   1920.) 


^0  \^^^ 


^"!  S". 


■=!  ;i 


htei^ASES   OF    CHILDREN 


;^^iTlie  boWels  shotil(J  be  Kept  open,  and  the  appetite  improved  by 
means  of  bitter  tonics,  especially  nnx  vomica  and  the  componnd  tincture 
of  cinchona. 

In  incipient  phthisis  it  is  very  rarely  necessary  to  resort  to  opiates 
or  its  derivatives  to  check  the  cough,  but  when  the  latter  is  distress- 
ing, especially  at  night,  those  remedies  should  be  cautiously  adminis- 
tered as  often  as  indicated. 

The  management  of  advanced  cases  of  tuberculosis  of  the  lungs  is 
essentially  the  same  as  in  incipient  cases,  except  that  one  is  often 
called  upon  to  arrest  hemoptysis  (ice  bag  to  chest,  morphine  hypo- 
dermically),*  and  to  check  hyperidrosis  (sponging  of  the  body  with  a 
strong  alum  solution,  atropine  by  mouth  or  hypodermically),  and 
to  strengthen  the  heart's  action  (digitalis  and  strychnine).  In  the 
presence  of  the  aforementioned  complications,  however,  very  few 
children  survive — do  what  you  will.     Like  the  flickering  flame  of  the 


Fig.  109. — Tuberculosis  of  the  brain  (boy  four  years  old).  During  the  protracted 
course  of  the  disease  a  marked  hypertrichosis  developed  over  the  entire  body,  espe- 
cially the  legs. 

candle  end,  after  many  ups  and  downs,  slowly  but  surely,  life  is  ex- 
tinguished— often  at  a  time  when  the  patient  seems  on  the  mend. 

Tuberculosis  of  the  Brain 

Brain  tuberculosis  occurs  in  children  (1)  as  a  partial  manifestation 
of  general  tuberculosis,  (2)  as  tuberculous  meningitis,  and  (3)  as 
brain  tumors.  The  brain  lesions  are  essentially  the  same  in  the  three 
clinical  types  of  the  disease.  They  consist  in  the  deposit  of  tubercles 
in  the  brain  substance  which  vary  in  size  from  a  millet  seed  to  that  of 
a  hen's  egg.  In  tuberculous  meningitis  w-e  find,  in  addition,  inflam- 
mation of  the  pia  mater  of  the  brain  and  sometimes  also  of  the  cord 
and  transudation  into  the  ventricles  {chronic  hydrocephalus).  The 
tubercles  are  usually  located  in  the  gray  matter — in  the  large  ganglia, 


*  Artificial  pneumothorax  may  be  resorted  to  in  older  children. 


SPECIFIC    COMMl'NICABLE   DISEASES  453 

in  tlie  pons  and  in  the  cerebellum — and  occasionally  also  in  the  white 
substance.  During  life,  however,  it  is  extremely  difficult  to  determine 
the  seat  of  the  lesion,  except  when  the  latter  is  large  enough  to  exert 
pressure  on  the  vital  structures  which  in  their  turn  give  rise  to  focal 
symptoms — as  for  example,  paralysis  of  the  cranial  nerves  in  the  dis- 
ease of  the  pons.  In  the  absence  of  such  symptoms  tuberculosis  of  the 
brain  may  exist  for  months  without  being  detected.  This  is  especially 
true  of  brain  tuberculosis  associated  with  tuberculosis  of  other  organs. 
As  the  disease  progresses,  the  symptomatology  becomes  clearer.  The 
child  suffers  from  intense  headache,  convulsions,  paresis  or  paralysis  of 
some  of  the  cranial  nerves  or  extremities,  but  even  then  it  is  often 
only  a  matter  of  conjecture  whether  these  pressure  symptoms  are  due 
to  tubercle  or  to  other  tumors.  (See  "Tumors  of  the  Brain,"  p.  645.) 
The  diagnosis  is  least  difficult  when  tuberculosis  of  the  brain  is  mani- 
fested by  meningitis.  (See  p.  614.)  Here  lumbar  puncture  and  the 
complement-fixation  reaction  (q.v.)  often  help  to  clear  up  the  diagnosis. 
Recourse  should  be  had  also  to  the  tuberculin  test,  examination  of  the 
sputum  for  tubercle  bacilli,  and  ophthalmoscopic  inspection  of  the  eyes 
for  choroidal  tubercules. 

Tuberculosis  of  the  Abdominal  Organs 

Aside  from  the  intestinal  tract  and  peritoneum,  the  spleen,  liver, 
pancreas,  diaphragm,  omentum,  suprarenals,  and  the  urogenital  sys- 
tem may  also  be  the  seat  of  tuberculous  disease.  Except  in  the  rare 
instances  of  invasion  of  the  abdominal  organs  by  tubercle  bacilli 
through  the  general  circulation  (blood  or  lymph  channels),  the  ab- 
dominal organs  usually  become  involved  secondarily  to  intestinal  or 
peritoneal  tuberculosis.  As  a  rule,  these  latter  structures  become 
infected  primarily  by  swallowing  of  food,  sputum  or  necrotic  tissue 
from  the  nasopharynx  contaminated  by  tubercle  bacilli. 

Tuberculous  Peritonitis 

This  condition  is  the  result  of  dissemination  of  tubercles  over  the 
peritoneum,  omentum,  and  adjacent  structures.  The  inflammation  ex- 
cited by  their  presence  gives  rise  to  a  serofibrinous  or  hemorrhagic 
exudation  with  gradual  agglutination  of  the  inflamed  portions,  case- 
ation and  ulceration.  Postmortem  examination  of  cases  of  long  stand- 
ing usually  reveals  involvement  of  the  mesenteric  and  retroperitoneal 
glands,  amyloid  degeneration  of  the  liver  and  spleen,  tuberculosis  of 
the    lungs,    and    parenchymatous    nephritis. 


454 


DISEASES   OF   CHILDREN 


Tuberculous  peritonitis  is  comparatively  rare  in  children  under 
three  years  of  age,  but  quite  frequent  in  those  over  this  age.  The 
classical  variety  of  tuberculous  peritonitis  is  the  chronic  form.  Oc- 
casionally, however,  it  may  pursue  a  subacute,  or  even  an  acute 
course  with  chills,  nausea,  vomiting,  acute  abdominal  pain,  and  high 
fever,  simulating  acute  perforative  peritonitis  of  appendiceal  origin. 
In  the  majority  of  instances  the  disease  sets  in  insidiously  with  symp- 
toms of  dyspepsia,  anemia,  evening  rise  of  temperature,  accelerated 
respiration  and  pulse,  frequent  attacks  of  colic  and  more  or  less  pro- 


Fig.  110. — Tuberculous  peritonitis  in  a  baby  fifteen  months  old ;  she  has  fully 
recovered  after  laparotomy.  The  von  Pirquet  test  was  negative  and  the  diagnosis 
was  based  chiefly  upon  the  differential  sign  mentioned  on  page  155. 


nounced  diarrhea.  Very  soon  the  characteristic  symptoms  of  the  dis- 
ease are  in  full  bloom.  The  abdomen  is  distended  and  its  wall  often 
glistening  and  traversed  by  blue  lines,  the  epigastric  veins.  The  um- 
bilicus is  either  effaced  or  protuberant.  The  extremities  are  ema- 
ciated and  contrast  strongly  with  the  gradually  enlarging  abdomen. 
Some  portions  of  the  abdomen  are  flat  on  percussion,  eliciting  the 
presence  of  fluid  or  nodular  masses,  other  portions  again  are  tympan- 


SPECIFIC    COMMUNICABLE   DISEASES  455 

itic,  denoting  that  part  of  the  abdominal  enlargement  is  due  to  in- 
testinal gases.' 

Palpation  sometimes  confirms  the  findings  on  percussion.  Occa 
sionally  hard,  cord-like,  painful  masses  and  thickened  omentum  or 
adherent  intestinal  loops  are  found,  of  more  rarely  large  tumors  or 
encapsulated  abscesses  are  detected.  The  latter  if  situated  near  the 
navel  (periumbilical  tuberculous  abscess)  may  open  and  discharge 
through  the  navel.  The  abdominal  enlargement  may  persist,  or  after 
disappearance  of  the  fluid  content  and  formation  of  fibrous  adhesions 
the  abdomen  may  retract,  become  tray-shaped,  and  remain  so  until 
exitus. 

If  not  arrested  by  therapeutic  measures  the  disease  usually  runs  a 
very  protracted  course — months  or  even  years.  Remissions  are  not 
rare,  but  sooner  or  later  the  symptoms  return,  sometimes  in  acute 
form;  the  patient  wastes  away,  is  troubled  by  hectic  fever,  sweats, 
diarrhea,  hiccough,  vomiting,  dysuria,  anuria,  and  edema  of  the  lower 
extremities  or  general  anasarca,  until  death  finally  relieves  him  of 
his  agony.  Fatal  issue  may  occur  also  from  intercurrent  diseases, 
such  as  intestinal  perforation,  tuberculosis  of  the  meninges  or  lungs. 

On  the  other  hand,  the  prognosis  is  not  as  grave  if  treatment  is 
instituted  early,  provided,  of  course,  that  the  disease  is  limited  to  the 
peritoneum. 

Unfortunately  in  the  early  stage  of  the  disease,  the  symptoms  are 
not  infrequently  masked,  and  a  positive  diagnosis  cannot  be  arrived 
at  until  the  pathognomonic  signs  of  the  disease  have  made  their  ap- 
pearance, i.  e.,  abdominal  distention,  circumscribed  dulness,  emaciation, 
diarrhea  (diarrhea,  emaciation  and  glandular  swelling  are  often  ab- 
sent), hectic  fever,  and  swelling  of  the  inguinal  glands.  Even  then  the 
peritonitis  may  be  confounded  with  ascites,  accompanying  cirrhosis 
of  the  liver  or  valvular  heart  disease.  In  such  cases  the  diagnosis  may 
sometimes  be  settled  by  the  tuberculin  tests,  by  a  bacteriologic  exam- 
ination of  aspirated  abdominal  fluid  or  by  inoculation  experiments. 
(See  also  "Chronic  Abdominal  Enlargement,"  p.  151.) 

Treatment. — As  spontaneous  cure  is  extremely  rare  and  radical 
cures  by  laparotomy  are  quite  frequent  (about  50  per  cent),  the  latter 
mode  of  treatment  should  be  resorted  to  as  soon  as  practicable.  Some 
authors  attribute  the  curative  effect  of  laparotomy  to  the  admission 
of  atmospheric  air  to  the  abdominal  cavity,  others  to  hyperemia  of  the 
peritoneum  produced  by  the  operation  in  a  manner  similar  to  that  em- 
ployed by  Bier  in  the  cure  of  tuberculosis  of  the  extremities.  Ex- 
cept abundance  of  sunshine,  sojourn  at  the  seashore  or  mountains  and 


456  DISEASES   OF    CHILDREN 

plenty  of  wholesome  food — which  measures  should  be  employed  also 
in  conjunction  with  an  operation — all  other  medical  procedures  are 
only  of  temporary  benefit. 

Intestinal  Tuberculosis 

(Tabes  Mesenteric  a) 

According  to  Hess,  the  bovine  type  of  tubercle  bacilli  is  responsible 
for  60  per  cent  of  these  cases.  The  tuberculous  lesions  are  usually 
found  in  the  lowest  portions  of  the  ileum,  ileocecal  region  and  colon. 
It  is  manifested  by  a  tuberculous  infiltration  of  the  solitary  follicles 
and  mucosa  of  the  intestines,  which  gradually  undergo  softening  and 
caseation  and  finally  break  down,  leaving  behind  annular  ulcers.  Tu- 
berculous inflammation  of  the  large  intestine  may  produce  so  much 
swelling  as  to  occlude  the  intestinal  lumen.  Sooner  or  later  the  inflam- 
mation extends  to  the  mesenteric  glands  and  the  peritoneum.  Occa- 
sionally the  lungs  and  other  organs  become  involved. 

All  these  manifestations,  however,  are  observed  only  at  the  autopsy. 
During  life  the  symptoms  are  very  obscure.  Palpation  may  reveal  en- 
larged mesenteric  glands  deep  down  in  the  abdomen,  but  more  fre- 
quently owing  to  meteorism  they  escape  observation,  and  even  if  pal- 
pable are  not  invariably  tuberculous  in  nature.  If,  however,  this  symp- 
tom is  associated  with  enlargement  of  the  other  glands  of  the  body,  stub- 
born diarrhea  (greenish-gray  in  color,  mixed  with  mucus,  pus,  and  of- 
ten blood),  emaciation  and  cachexia,  sweats  and  hectic  fever,  the  diag- 
nosis of  intestinal  tuberculosis  is  fairly  certain.  The  diagnosis  is  ren- 
dered positive  by  the  demonstration  of  tubercle  bacilli  in  the  stools. 
The  tuberculin  test  and  examination  of  the  sputum  often  prove  decisive 
in  doubtful  cases;  and  complications,  such  as  perforation  of  the  intes- 
tines with  consecutive  peritonitis,  settle  the  diagnosis  beyond  a  doubt. 
Indeed,  in  the  majority  of  instances  the  diagnosis  cannot  be  made  until 
these  complications  arise,  a  period  at  which  therapeutic  measures  al- 
most invariably  fail.     At  all  events  the  prognosis  is  extremely  grave. 

Cases  of  local  tuberculosis  detected  early  and  treated  energetically 
(chiefly  surgically)  may  recover. 

Tuberculosis  of  the  Genitourinary  Tract 

Urogenital  tuberculosis,  especially  tuberculosis  of  the  kidneys,  is 
comparatively  common  in  children.  It  occurs  either  as  a  manifes- 
tation of  general  tuberculosis  or  as  an  independent  disease.  In 
the  latter  event  it  almost  invariably  begins  in  one  kidney,  and  from 


SPECIFIC    COMMUNICABLE   DISEASES 


457 


here  it  spreads  to  the  l)hidder,  and  to  the  other  kidney.  In  the  be- 
ginning the  affection  is  very  apt  to  be  overlooked,  but,  as  the  tubercu- 
lous process  advances,  the  symptoms  (pain  in  the  region  of  the  kidney 
and  ureter,  thickening  of  the  ureter — as  evinced  by  palpation  with  the 
finger  in  the  rectum  or  vagina — irritability  of  the  bladder,  albumin- 
uria, pyuria,  and  often  hematuria)  become  sufficiently  characteristic 
as  to  demand  careful  repeated,  bacteriologic  examination  of  the  urine 


□ 

Fig.  111. — Characteristic  early  tuber- 
cular infiltration,  as  seen  through  the 
cystoscope.      (Lcedham-Green.) 


Fig.  112.- — A  large  tubercular  ulcer  be- 
low the  orifice  of  the  right  ureter. 
(Leedham -Green.) 


Fig.  113. — Cystoscopic  view  of  the  base  of  the  bladder  in  a  case  of  tuberculosis 
of  the  left  kidney  (Wyatt).  The  opening  of  the  right  ureter  is  normal;  the  open- 
ing of  the  left  ureter  is  seen  to  be  gaping,  the  lips  edematous  and  thickened,  show- 
ing the  presence  of  small  miliary  tubercles. 


for  tubercle  bacilli,  and  cystoscopic  inspection  of  the  bladder  for  tu- 
berculous lesions.  Even  in  the  early  stage,  systematic  cystoscopic 
examination  of  the  bladder  will  rarely  fail  to  detect  tuberculous  nod- 
ules and  ulceration  about  the  opening  of  one  ureter  (Fig.  113).     In 


458  DISEASES    OF    CHILDREN 

cases  of  long  standing  the  lesions  are  often  scattered  throughout  the 
bladder.  As  in  tuberculosis  of  the  other  organs,  the  tuberculin  test 
should  always  be  employed  to  corroborate  the  diagnosis.  Early  recogni- 
tion of  the  condition  and  prompt  surgical  treatment  are  not  rarely 
followed  by  permanent  recovery. 

Scrofulosis 

(Tuberculosis  of  the  Skin,  Mucous  Membranes  and  Glands) 

The  tuberculous  symptom-complex  presently  to  be  described  should 
not  be  confounded  with  similar  groups  of  symptoms  which  are  tran- 
sient in  character  and  generally  due  to  strepto-  and  staphylococcus  in- 
fection. Genuine  scrofulosis  attacks  children  with  undermined  consti- 
tutions who  are  poorly  fed  and  cared  for,  forced  to  live  in  damp,  dark 
and  filthy  dwellings,  and  who  are  exposed  to  tuberculous  infection. 
Various  skin  eruptions,  or  injuries,  exanthemata,  decayed  teeth,  and 
diseased  tonsils  and  adenoids,  among  others,  serve  as  the  portals  of  en- 
try to  the  tubercle  bacilli.  The  immediate  result  of  the  tubercular  infec- 
tion is  hyperplasia,  and  the  more  remote  effect,  caseous  degeneration  of 
the  parts  primarily  involved,  and  frequently  secondary  infection  of  the 
neighboring  structures. 

Clinically,  scrofulosis  is  characterized  by  simultaneous  or  successive 
involvement  of  the  skin,  mucous  membranes  and  lymphatic  glands; 
chronicity  of  its  course,  and  a  tendency  toward  slow  spontaneous  re- 
covery, or  transition  into  general  tuberculosis. 

The  skin  is  the  seat  of  a  pustular  eruption  which  resists  ordinary 
local  treatment,  generally  involves  the  subcutaneous  tissue,  and  breaks 
down,  forming  slowly  discharging  abscesses  or  indolent  ulcers.  It  is 
most  frequently  situated  upon  the  back  and  nates,  but  is  found  also 
upon  the  scalp  and  face — probably  carried  from  one  part  to  the  other 
by  scratching  by  means  of  infected  fingers. 

Scrofulosis  of  the  mucous  membranes  is  manifested  chiefly  by  naso- 
pharyngitis. From  the  nasopharynx  the  inflammatory  process  may 
spread  to  the  ears,  eyes,  larynx  and  oral  cavity. 

The  nasal  mucous  membrane  is  red  and  swollen  and  discharges  a 
seropurulent  secretion  which  forms  yellowish-green  crusts  within  and 
around  the  nares,  producing  snuffling  respiration  and  excoriation  of 
the  upper  lip.  A  similar  acrid  discharge  is  usually  observed  from  the 
ears  (bilateral  otorrhea).  Both  the  nasal  and  aural  discharges  may  be-, 
come  purulent  and  fetid ;  in  the  first  instance,  by  extension  of  the  inflam- 
mation from  the  nasal  mucous  membrane  to  the  cartilage,  periosteum 


SPECIFIC    COMMUNICABLE   DISEASES 


459 


and  even  nasal  bones  (sometimes  marked  nasal  deformity)  ;  in  the  sec- 
ond instance,  by  implication  of  the  middle  ear  and  eventually  the  ossi- 
cles, or  petrous  portions  of  the  temporal  bones. 

Scrofulosis  of  the  eyes,  the  so-called  strumous  ophthalmia,  usually 
begins  with  redness  and  swelling  of  the  palpebral  mucous  membrane, 
and  in  the  majority  of  cases  is  soon  followed  by  involvement  of  the 
cornea,  in  the  form  of  phlyctenular  keratitis^  with  strong  lacrimation, 
pain,  and  photophobia.  The  phlyctenulsB  are  very  slow  in  healing,  and 
show  a  great  tendency  to  leave  behind  corneal  opacities.  Blepharo- 
adenitis,  madarosis  and  permanent  thickening  of  the  edges  of  the  lids  are 
quite  common  accompaniments. 


Fig.  114. — Tuberculous  axillary  lymphadenitis. 


The  lymphatic  glands  are  affected  early  or  late — secondary  to  the  in- 
flammation of  the  skin  and  mucous  membranes.  Except  their  wide 
distribution,  the  glandular  swellings  present  nothing  characteristic  in 
the  beginning,  but  as  the  disease  progresses  they  show  a  marked  ten- 
dency to  undergo  caseation  and  suppuration.  Furthermore,  after  evac- 
uation of  the  pus  which  usually^  contains  tubercle  bacilli,  they  rarely 
cicatrize,  but,  on  the  contrary,  continue  as  pus-discharging  fistulae 
or  indolent  ulcers. 


460  DISEASES    OP    CHILDREN 

The  course  of  the  disease  depends  greatly  upon  the  vitality  of  the 
patient  and  the  mode  of  treatment.  It  is  always  chronic.  Children  re- 
moved from  .the  obnoxious  surroundings  frequently  recover  completely. 
In  those  not  properly  cared  for,  the  tuberculous  process  is  very  prone  to 
spread  to  the  osseous  system  and  to  the  internal  organs.  Spina  ven- 
tosa,  osteomyelitis  and  spondylitis  form  frequent  sequelse.  (For  de- 
tails of  these  affections  the  reader  is  referred  to  the  chapter  on  "Tu- 
berculosis of  the  Bones,"  p.  761.)  The  internal  organs,  especially  th6 
liver,  spleen  and  lungs,  may  be  implicated  singly  or  collectively,  in  which 
event  the  prognosis  of  course,  is  extremely  bad. 

Characteristic  as  the  symptom  complex  of  scrofulosis  seems  to  be, 
errors  of  diagnosis  are  nevertheless  very  apt  to  be  made.  The  perplex- 
ity is  often  great  in  the  differentiation  between  scrofula  and  inherited 
syphilis,  both  of  which  diseases  have  many  symptoms  in  common.  In 
all  such  doubtful  cases,  it  is  wise,  on  the  one  hand  to  employ  the  tu- 
berculin reaction,  and  examine  the  aural  and  nasal  secretions  as  well 
as  the  pus  from  scrofulous  abscesses  for  tubercle  bacilli,  and,  on  the 
other,  to  administer  mercury  and  to  look  for  the  Spirochete  pallida. 
One  should  not  be  too  hasty  in  pronouncing  a  case  as  scrofulosis  be- 
cause of  the  so-called  "torpid  habitus"  of  the  patient  (pale,  flabby, 
puffed  face,  thick  nose,  swollen  and  excoriated  upper  lip,  redness  and 
thickening  of  the  lids),  or  the  presence  of  adenoids  or  glandular  swell- 
ing. These  symptoms  can  and  often  do  exist  independently  of  tuber- 
culosis, and,  as  already  suggested,  may  be  due  fo  infection  by  other  mi- 
croorganisms. 

Treatment. — Scrofula,  like  other  forms  of  tuberculosis,  demands 
early  and  energetic  treatment.  The  patient  should  be  removed  from  the 
obnoxious  influences,  should  be  well  nourished  and  kept  outdoors  the 
greater  part  of  the  day.  (See  p.  449.)  Under  suitable  conditions  he 
should  also  be  given  the  benefit  of  tuberculin  therapy  {q.  v.).  Internally 
we  should  administer,  for  several  months  in  succession,  moderately  large 
doses  of  the  syrup  of  the  iodide  of  iron  and  syrup  of  the  hypophosphites, 
as  well  as  cod  liver  oil  or  similar  alterative  tonics.  The  local  treat- 
ment, which  is  of  very  great  importance,  essentially  consists  of  thorough 
bodily  cleanliness  (daily  bath  with  sea  salt,  antiseptic  dressings  in  open 
wounds,  etc.)  ;  removal  of  diseased  foci  such  as  tonsils  and  adenoids,  de- 
cayed teeth,  caseated  glands,  etc.,  and  evacuation  of  pus  wherever 
found.  Individual  complications  should  be  vigorously  combated  accord- 
ing to  indications.  (See  bone  tuberculosis,  otitis,  eczema,  etc.)  As  the 
external  lesions  are  probably  carried  from  place  to  place  by  means  of 
the  fingers,  open  wounds  (vaccination  wounds!)  should  be  thoroughly 


SPECIFIC    COMMUNICABLE   DISEASES 


40 1 


protected  and  the  patient's  finger  nails  clipped  and  kept  scrnpulously 
clean  to  prevent  scrateliing  the  diseased  parts  of  the  body  and  direct 
infection  of  its  healthy  portions. 

IJ     Syr.  Ferri  lodidi  3  iv  15.00 

Syr.  Calcii  et  Sodii 

Hypopliospliitum  q.  s.  ad  f  3  ii  CO.OO 

M. 
S. — One  teaspoonful  three  times  a  daj-  for  a  child 
three  years  ohl. 

TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Tubercular  Osteomyelitis  and  Arthritis 

The  grouping  together  of  tuberculous  bone  and  joint  diseases  is 
intended  to  emphasize  their  correlation.  The  favorite  seat  of  bone 
tuberculosis  is  usually  in  the  epiphyses,  the  joint  becoming  involved 


Fig.   llo. — Tiihcrculosis   of  elbow  joint   in   a  boy   eighteen  months   old.     Note   dis- 
charging sinus. 


462  DISEASES   OP   CHILDREN 

secondarily  by  extension  of  the  inflammatory  process  to  the  syno- 
vial structures.     Occasionally,  the  joint  is  affected  primarily. 

The  immediate  cause  of  the  disease  is  the  tubercle  bacillus  which 
invades  the  medullary  tissue,  the  bone  proper,  or  the  articular  struc- 
tures, either  from  within — from  a  florid  or  latent  tuberculous  focus 
elsewhere — or  from  without,  as  a  result  of  traumatism.  An  inherited 
predisposition  and  impaired  nutrition  from  various  causes  favors  the 
development  of  tuberculous  disease. 

Osseous,  as  well  as  articular,  tuberculosis  is  essentially  a  chronic  in- 
flammatory process,  free  from  the  violent  symptoms  which  are  char- 
acteristic of  acute,  nontuberculous  osteomyelitis.  Extensive  lesions 
may  exist  for  weeks  and  months  with  apparently  perfect  health.  Fever 
is  usually  absent  in  the  beginning  and  only  slight — in  the  evening— 
at  a  later  stage  of  the  disease.  As  the  tuberculous  process  advances, 
progressive  anemia  and  emaciation  make  their  appearance,  but  are 
not  pathognomonic  of  the  affection.  The  local  symptoms  also  are 
very  vague  at  first.  Hence  the  reason  why  local  tuberculous  disease 
is  frequently  overlooked  until,  as  will  presently  be  shown,  deformity 
and  loss  of  function  have  occurred,  which  vary  greatly  in  extent  and 
severity  with  the  seat  of  the  lesions  and  the  mode  of  treatment. 

Tuberculosis  of  the  Vertebral  Colrunn 

(Spondylitis.    Pott's  Disease) 

This  tuberculous  process  usually  begins  in  or  near  the  vertebral  body, 
and  if  not  arrested,  gradually  extends  to  the  contiguous  structures,  in- 
cluding the  spinal  cord. 

It  is  manifested  by  an  ulcerative  and  often  suppurative  destruction 
of  the  bone,  with  metastatic  (gravitation)  abscesses  in  distant  locations, 
e.  g.,  retropharyngeal  abscess,  in  cervical  spondylitis ;  psoas  abscess,  in 
lower  dorsal  and  lumbar  disease.  Furthermore,  with  softening  and 
crumbling  of  the  vertebral  bodies,  the  spinal  column,  as  it  were,  top- 
ples over,  usually  backward,  producing  a  deformity  known  as  kyphosis, 
gibbus  or  Pott's  hump.  The  condition  is  gradually  further  aggravated 
by  compensatory  spinal  deformities  (especially  lordosis)  and  a  group 
of  other  distressing  pressure  symptoms,  soon  to  be  related,  which  if  not 
arrested  throw  the  unfortunate  creature  in  an  abyss  of  everlasting 
misery. 

This  process,  fortunately,  is  very  slow  in  development,  affording  am- 
ple time^from  three  to  ten  years — to  arrest  and  mend  its  ravages  and 
ample  warnings  to  the  patient  to  seek  relief.  We  may  frequently  dif- 
ferentiate four  stages  in  the  progress  of  the  affection:     (1)  The  stage 


SPECIFIC    COMMUNICABLE   DISEASES 


463 


of  onset,  where  the  symptoms  are  very  vague  and  inconstant.  The 
child  shows  a  disinclination  to  play,  refuses  to  walk,  or  tires  easily  when 
he  does  walk.  He  complains  of  pain  in  different  parts  of  the  body,  fol- 
lowing the  distribution  of  the  spinal  nerves,  the  pain  being  often  so 
severe,  especially  at  night,  that  it  wakes  the  child  from  his  sleep  with 
a  sudden  start — •  "starting  pain";  (2)  the  stage  of  fixation  of  the  spinal 
column;  (3)  the  stage  of  characteristic  deformity;  and  (4)  the  stage  of 
suppuration  and  pressure  paralysis.  The  disease  does  not  always  pro- 
gress to  the  last  stages.  In  some  instances,  after  two  or  three  years' 
course,  either  through  treatment  or  spontaneously,  solidification  of  the 


Fig.  116. — Pott's  disease  (Langerhans  and  Brooks,  F.  A.  Davis  Co.).  Kyphosis 
of  dorsal  vertebra3,  the  result  of  caseous  tuberculous  periostitis  and  osteomyelitis. 
Destruction  of  three  thoracic  vertebrae.     Two-thirds  natural  size. 


diseased  vertebra3 — a  relative  cure — occurs.  Relapses,  however,  are  not 
infrequent.  Pressure  paralysis  (see  ''Myelitis,"  p.  656)  is  especially 
common  in  disease  of  the  lower  cervical  and  upper  dorsal  regions. 

The  focal  symptoms  vary  with  the  seat  and  extent  of  the  lesion.  In 
cervical  spondylitis  the  patient,  if  old  enough,  complains  of  neuralgic 
pain  in  the  head  and  upper  portion  of  the  neck.  Very  young  chil- 
dren indicate  the  presence  of  pain  by  a  suffering  and  an  anxious  expres- 
sion of  the  face,  by  refusal  of  food  and  crying  on  handling.  The  head 
is  stiff,  tipped  backward  or  laterally   (torticollis-like),  and,  when  the 


464  DISEASES   OF    CHILDREN 

child  moves,  he  is  often  seen  to  support  his  head  with  the  hands.  At 
a  later  stage  of  the  disease,  there  are  often  disturbances  of  deglutition 
and  phonation,  not  rarely  due  to  tubercular  retropharyngeal  abscess.  If 
the  uppermost  cervical  vertebra?  are  diseased,  there  is  danger  of  ante- 
rior displacement  of  the  head  between  the  atlas  and  axis,  more  rarely 
between  the  occiput  and  atlas,  and  death  from  pressure  upon  the  cord. 
The  permanent  deformity   in   cervical   spondylitis  usually   consists   of 


Fig.  117.  Fig.  118. 

Fig.  117. — Eigiclity  of  neck  associated  with  "cervical  ribs."  For  over  two  years 
patient  was  treated  by  eminent  orthopedic  surgeons  for  cervical  spondylitis  until  a 
roentgenogram  revealed  the  error  in  the  diagnosis. 

Fig.  118. — Same  case  as  in  Fig.  117  showing  peculiqr  attitude  of  head  which  led 
to  the  erroneous  diagnosis. 

thickening  and  broadening  of  the  neck,  and  sinking  of  the  head  upon 
the  shoulders. 

In  dorsal  spondylitis  the  distribution  of  the  pain  differs  somewhat 
with  the  particular  part  of  the  spine  involved.  If  the  upper  dorsal  ver- 
tebrae are  affected,  the  pain  resembles  that  of  intercostal  neuralgia,  and 
increases  on  coughing,  sneezing,  laughing,  etc.,  while  in  spondylitis  of 


SPECIFIC    COMMUNICABLE   DISEASES 


4G5 


the  lower  dorsal  vertebrae,  the  most  frequent  seat  of  the  disease,  the 
pain  radiates  to  the  lower  extremities.  In  disease  of  this  region,  fur- 
thermore, the  upper  part  of  tlie  body  deviates  to  the  side,  one  shoulder 
is  elevated  and  the  trunk  bent  to  tlie  opposite  side — a  state  of  scoliosis; 
at  the  same  time  the  vertebral  column  is  kept  rigid,  every  movement 
carefully  avoided,  and,  in  walking,  short  rigid  steps  are  taken,  the  pa- 
tient timidly  balancing  the  superincumbent  weight  of  the  body  \>y 
firmly  supporting  the  spine  with  the  hands.  If  urged  to  pick  up  some- 
thing from  the  floor,  the  child  stoops  by  strongly  flexing  the  knee- 


Fig.  119. — Advanced  dorsal  spondylitis  with  gibbus. 


and  hip-joints,  while  holding  the  vertebral  column  perfectly  rigid,  and 
raises  himself  by  resting  the  hands  upon  the  thighs,  and  then,  with 
alternating  supporting  movements  along  the  thighs  and  trunk,  elevates 
the  body  and  lastly  extends  the  legs.  If  bending  of  the  spinal  column  is 
attempted,  motion  occurs  only  in  the  healthy  sections,  the  diseased  por- 
tions remaining  firmly  fixed.  The  ultimate  spinal  deformity  consists  of 
kyphosis,  kyphoscoliosis  and  lordosis. 

In  lumbar  disease  the  patient  complains  of  pain  in  sitting,  and  refers 
it  also  to  the  lowest  portion  of  the  abdomen  and  the  legs.    The  physical 


466  DISEASES   OP   CHILDREN 

signs  are  essentially  the  same  as  in  spondylitis  of  the  lower  dorsals, 
except  that  the  deformity  occurs  at  a  later  period  and  is  not  as  pro- 
nounced. On  the  other  hand,  there  is  a  greater  tendency  toward  the 
formation  of  psoas  adscess —  a  tumor  deep  in  the  iliac  fossa  or  at  the 
anterior  surface  of  the  thigh,  lameness  and  flexion  of  one  thigh. 

Careful  attention  to  the  aforementioned  physical  signs  rarely  fails 
to  disclose  the  presence  of  vertebral  caries,  even  at  an  early  stage  of 
the  disease.  Cervical  spondylitis  may  be  mistaken  for  torticollis  (sud- 
den onset,  pain  and  unilateral  contracture  more  pronounced;  early  re- 
sponse to  anodynes  and  antirheumatics,  etc.)  ;  for  cervical  rib  (re- 
vealed by  x-ray)  ;  nontuherculous  retropharyngeal  abscess  (immediate 
relief  on  puncture).  Dorsal  and  lumbar  spondylitis  may  be  confounded 
with  rachitic  curvature  (rounded  in  rickets;  angular  in  spondylitis: 
rachitic  kyphosis  is  reducible  by  placing  the  child  upon  the  abdomen 
and  overextending  the  thighs ;  absence  of  characteristic  gait  and  mode 
of  stooping).  Right  iliac  psoas  abscess  often  resembles  appendicitis 
(onset  sudden  or  recurrent,  rigidity  of  the  abdominal  muscles,  absence 
of  spinal  disease).  Psoas  abscess  differs  from  liip-joint  disease,  by  the 
hip- joint  being  fixed  in  the  latter  affection ;  and  from  hernia,  by  the  latter 
being  reducible  in  recumbent  posture. 

In  view  of  the  comparatively  slow  course  of  the  disease  in  the  major- 
ity of  cases,  the  prognosis  as  to  life  is  good,  and  as  to  permanent  de- 
formity fair,  provided  the  treatment  is  begun  early  and  persisted  in. 
The  prognosis  is  bad  in  cases  presenting  abscesses,  fistulas,  and  pressure 
paralysis.  Even  here  surprisingly  good  results  are  often  obtained  un- 
der suitable  treatment. 

Treatment. — The  treatment  is  principally  orthopedic  and  surgical — 
fixation  of  the  spine  by  a  plaster  of  Paris  or  (in  milder  cases)  cellu- 
loid jacket,  rest  in  bed  to  unburden  the  spinal  column,  and  evacua- 
tion of  large  collections  of  pus  (e.  g.,  retropharyngeal  or  psoas  ab- 
scesses). The  F.  M.  Albee  method  of  bone-grafting  has  proved  emi- 
nently successful  in  a  great  many  cases.  Good  hygiene,  outdoor  air, 
plenty  of  nutritious  food,  and  iron,  hypophosphites  and  cod  liver  oil 
will  facilitate  a  cure. 

Morbus  Coxarius 

(Hip- Joint  Disease.    Coxitis  Tuberculosa.    Articular  Osteitis  of  the 

Hip) 

The  pathologic  process  of  this  tuberculous  affection  is  usually  de- . 
scribed  as  consisting  of  three  stages     (1)  The  stage  of  ostitis,  as  a  rule, 
involving  the  femoral  head,  less  frequently  the  acetabulum;    (2)    the 


SPECIFIC    COMMUNICAnLE   DISEASES 


467 


sta<?e  of  arthritis  or  suppuration,  in  which  all  the  joint  structures  are 
implicated;  and  (3)  the  stage  of  disintegration  and  absorption  of  the 
head  and  sometimes  the  neck  of  the  femur  and  the  upper  and  back  part 
of  the  acetabulum,  with  "wandering"  of  the  head  of  the  femur  upward 
and  backward  upon  the  dorsum  ilii. 

Simultaneously  with  the  onset  of  the  first  stage  of  the  pathologic 
process,  or  sometimes  at  a  later  period,  the  child  begins  to  limp  and  to 


Fig.  120. — Tuberculous  coxitis,  advanced  stage. 

complain  of  pain  in  the  knee-  or  hip-joint  or  both.  As  a  rule,  the  limp 
at  first  is  intermittent  in  character,  more  marked  either  in  the  morning 
or  in  the  evening,  but  as  the  inflammation  progresses,  it  becomes  con- 
stant and  quite  pronounced,  the  leg  at  the  same  time  being  held  very 
rigid.  With  the  occurrence  of  articular  exudation,  the  leg  assumes  a 
pathognomonic  position  of  flexion,  abduction  and  eversion,  and  the  pa- 
tient in  order  to  bring  the  foot  to  the  ground  depresses  the  pelvis  on 
the  affected  side,  this  giving  rise  to  slight — apparent — lengthening  of 


468 


DISEASES    OP    CHILDREN 


the  limb.  With  destruction  of  the  joint  and  the  articuhir  bony  struc- 
tures, the  hip-joint  becomes  further  flexed,  inverted  and  adducted.  To 
overcome  the  uselessness  of  the  limb  in  this  position  the  patient  ele- 
vates the  pelvis  on  the  affected  side,  and  to  counteract  the — apparent — 
shortening,  he  steps  on  the  ball  of  the  foot.  Later  real  shortening  en- 
sues, owing  to  the  wandering  of  the  femoral  head  upward  and  back- 
ward, and  the  firm  contraction  and  atrophy  of  the  muscles. 


Fig.  121. — Early  stage  ol:  liip-joint  disease 


In  consequence  of  the  pelvic  obliquity,  in  the  upright  posture,  the  pa- 
tient assumes  a  position  of  compensatory  scoliosis  and  lordosis.  In 
the  recumbent  posture,  with  the  limbs  brought  down  parallel  to  each 
other,  there  is  always  compensatory  lordosis  of  the  lumbar  region.  This 
lordosis  disappears  on  flexing  the  affected  limb  at  the  hip  to  an  angle 
at  which  it  is  held  flexed  by  the  contracted  muscles. 

The  intensity  of  the  pain  varies.  It  is  usually  worse  after  manipu- 
lation and  fatigue,  and  at  night.     It  may  awaken  the  child  from  his 


SPECIFIC    COMMUNICABLE   DISEASES  469 

sound  sleep  with  a  cry  {"starting  pain").  The  pain  not  rarely  is  re- 
ferred to  the  knee,  or  to  other  parts  supplied  by  the  obturator  nerve, 
e.  g.,  the  inner  side  of  the  thigh.  Hence  the  importance  of  always  ex- 
amining the  hip-joint  in  such  eases. 

In  addition  to  the  pain,  the  limp  and  false  position,  we  may  find,  at  a 
late  stage  of  the  disease,  involvement  of  the  inguinal  glands,  with  or 
without  suppuration  and  perforation;  enlargement — ''white  swelling" 
— of  the  hip ;  flattening  of  the  gluteal  region  and  effaeement  of  one  glu- 
teal fold ;  multiple  abscesses  and  fistulae  at  various  points  of  the  hip  or 
thigh,  especially  at  the  tensor  fasciae  latye,  and  irregular  temperature,  es- 
pecially during  the  stage  of  suppuration. 

Cases  presenting  the  aforementioned  typical  symptoms  are  recogniza- 
ble at  a  glance.  Indeed,  at  this  very  late  stage  of  the  disease,  it  is  al- 
most immaterial  whether  a  correct  diagnosis  is  made  or  not,  since  a  fa- 
tal issue  from  exhaustion,  amyloid  degeneration  and  general  tubercu- 


Yig.  122. — Hip-joiut  disease.     Note  compensatory  lordosis  on  full  extension  of  af- 
fected limb. 

losis  is  all  that  can  be  expected,  particularly  in  children  with  a  tubercu- 
lous diathesis.  The  center  of  the  physician 's  interest,  therefore,  should 
rest  upon  the  diagnosis  of  incipient  coxitis,  which,  if  properly  treated, 
offers  good  prospect  of  recovery.  A  history  of  slight  trauma ;  occasional 
dragging  of  the  leg  or  limping ;  pain  in  the  hip-  or  knee-joint ;  disin- 
clination to  play  and  undue  fatigue  after  slight  exertion;  restless  sleep 
and  "starting  pain,"  all  point  to  coxitis  and  demand  very  careful  and 
repeated  examinations  of  the  hip-joint.  The  diagnosis  is  greatly  facil- 
itated and,  in  the  majority  of  instances,  rendered  positive  by  the  pres- 
ence of  pain  on  pressure  against  the  trochanter,  or  against  the  ace- 
tabulum (by  digital  rectal  examination),  and  by  von  Pirquet's  tuber- 
culin test.  Advanced  coxitis  can  readily  be  diagnosed  by  the  afore- 
mentionedf  faulty  attitude  of  the  patient,  in  recumbency,  standing,  or 
walking.     In  doubtful  cases,  an  x-ray  examination  (by  an  experienced 


470  DISEASES   OF    CHILDREN 

radiographer)  is  decisive.  The  latter  procedure  is  especially  useful  in 
differentiating  coxitis  from:  Injury  to  the  hip  (disability  follows  imme- 
diately after  the  accident;  local  signs  of  injury,  e.  g.,  ecchymosis,  etc.)  ; 
coxa  vara  (x-ray  shows  downward  inflexion  of  the  neck  of  the  femur; 
adduction  and  extension  of  the  limb  are  usually  possible)  ;  congenital 
dislocation  of  the  hip  (history  of  lameness  from  birth;  absence  of  in- 
flammatory signs  or  limitation  of  motion)  ;  osteom,yelitis  with  separa- 
tion of  the  epiphyses  (very  violent  course)  ;  rheumatisin  (yields  to  the 
salicylates;  no  bone  lesion)  ;  spondylitis  of  the  lumbar  region  (distinct 
symptoms  of  spondylitis;  hip-joint  free);  hysteria  (absence  of  joint 
trouble,  best  proved  under  anesthesia,  and  by  means  of  x-ray)  ;  peri- 
osteal  sarcoma  (Fig.  476)  of  the  trochanter  (the  swelling  rapidly  in- 
creases in  size;  marked  dilatation  of  the  superficial  veins). 

Treatment. — The  treatment  consists  of  reduction  of  existing  deform- 
ity, either  gradually  (by  weight  and  pulley,  while  the  patient  is  in  bed) 
or  forcibly  (under  anesthesia) ;  disencumbrance  of  the  hip-joint  of  the 
body  weight,  at  first  by  rest  in  bed  (bed  extension  apparatus)  and  later 
by  means  of  an  extension-walking  apparatus  (to  enable  the  patient 
to  enjoy  fresh  air)  and,  finally,  fixation  of  the  hip-joint  by  a  plaster- 
of-Paris  spica  or  a  fixation  apparatus.  Fixation  of  the  joint  as  well 
as  extension  should  be  continued  for  some  time  after  apparent  recovery. 
Constitutional  treatment.  Massage  to  prevent  atrophy  of  the  muscles 
and  stiffness  of  the  healthy  joints. 

Knee-Joint  Disease 

(Tuberculosis  op  the  Knee- Joint,  White  Swelling) 

The  pathologic  process  of  tuberculosis  of  the  knee-joint  resembles 
that  of  the  hip.  It  may  begin  in  the  synovial  membrane  or  in  the  articu- 
lar ends  of  the  osseous  structures.  The  clinical  symptoms  are  practi- 
cally the  same,  whether  the  synovialis  has  been  affected  primarily  or 
secondarily.  They  consist  of  fusiform  swelling,  local  tenderness,  atro- 
phy of  the  thigh  and  calf  muscles,  flexion  and  slight  outward  rotation 
of  the  knee,  and  later  abscess  formation  (extra-  or  intra-articular). 
During  the  suppurative  stage,  less  frequently  in  the  absence  of  sup- 
puration, there  are  more  or  less  constitutional  symptoms,  such  as  ano- 
rexia, anemia,  emaciation  and  irregular  fever.  The  latter  is  quite  high 
in  the  presence  of  secondary  infection. 

The  tuberculous  process  pursues  a  rather  slow  course.  Not  rarely  it 
is  interrupted  by  prolonged  remissions.  Exacerbations  are  often  in- 
duced by  local  trauma  or  intercurrent  acute  diseases,  sometimes  after 


SPECIFIC    COMMUNICABLE   DISEASES  471 

an  "apparent"  cure  has  been  established.  The  prognosis,  as  a  whole, 
however,  is  favorable,  if  treatment  is  begun  early  and  properly.  The 
very  rarely  occurring  spontaneous  recovery  should  not  be  depended 
upon. 

Treatment. — Within  recent  years  the  treatment  of  tuberculosis  of 
the  knee-joint,  as  well  as  that  of  the  other  smaller  joints,  has  been  en- 


Fig.  123. — Tuberculosis  of  the  knee  in  a  tliirteen  month  old  infant  who  a  few  months 
later  succumbed  to  tuberculous  pyothorax. 

tirely  revolutionized.  Instead  of  resorting  to  immobilization,  resec- 
tion and  permanent  fixation.  Bier's  method  of  passive  hyperemia  has 
become  the  treatment  of  choice,  since  it  not  only  aids  nature  in  the 
healing  9f  the  tuberculous  process  but  tends  also  to  restore  the  nor- 
mal functions  of  the  affected  joint.     The  mode  of  procedure  is  very 


472  DISEASES    OF    CHILDREN 

simple.  A  soft  rubber  bandage  about  2  inches  in  width  is  applied  gently 
and  evenly  around  the  extremity  (over  a  light  flannel  bandage),  at 
some  distance  above  the  lesion,  e.  g.,  at  the  middle  or  upper  third  of  the 
femur  in  tuberculosis  of  the  knee-joint,  and  left  in  place  for  an  hour 
or  two,  once  or  twice  a  day.  If  the  bandage  is  properly  applied,  it  gives 
rise  to  no  pain,  or  interruption  of  the  pulse.  The  extremity  below  the 
bandage  soon  swells  slightly,  and  assumes  a  bluish-red  color,  but  re- 
mains warm.  The  favorable  results  obtained  from  this  mode  of  treat- 
ment of  tuberculous  joints  are  rather  slow  in  coming  (from  three  to 
nine  months),  but  in  uncomplicated  cases  well  worth  waiting  for.  Com- 
plications arising  should  be  treated  symptomatically.  Thus  cold  ab- 
scesses call  for  free  incisions  and  evacuation  (may  be  enhanced  by 
suction  with  Bier 's  cup )  of  the  necrosed  tissue ;  large  exudations  should 
be  treated  by  aspiration  and  injection  of  iodoform  emulsion  or  bis- 
muth paste*  and  the  general  health  should  be  improved  by  outdoor 
fresh  air,  nutritious  food,  tonics  (iron  and  cod  liver  oil),  massage  and 
hydrotherapy.  (For  differential  diagnosis,  see  ''Arthritis,"  p.  418.) 
Tuberculin  therapy  {q.v.)  is  of  undoubted  value  in  the  early  stage  of 
the  affection. 

Spina  Ventosa 

(Tuberculosis  of   the  Metacarpals  and  Phalanges,   Tuberculous 

Dactylitis) 

This  disease  most  frequently  affects  the  first  phalanx  of  the  index 
finger,  but  may  occasionally  be  found  simultaneously  in  several 
phalanges  or  metacarpals  of  the  same  hand.  The  osseous  tissue  is  grad- 
ually destroyed,  and  while  this  is  going  on,  here  and  there  new  bone 
tissue  is  gradually  formed  under  the  periosteum.  In  consequence  of 
the  latter  process,  the  finger  becomes  fusiform,  as  if  the  bone  had  been 
"blown  up"  (see  Fig.  124).  As  the  inflammatory  process  is  very  slow 
and  painless,  it,  as  a  rule,  takes  several  months  before  the  characteristic 
appearance  is  developed.  At  a  later  stage  of  the  disease,  there  is  cir- 
cumscribed redness,  fluctuation,  impairment  of  function  of  the  tendons 
and  spontaneous  rupture  of  the  suppurating  focus  with  very  tedious 
discharge  of  the  contents. 

Tuberculous  dactylitis  may  be  mistaken  for  a  congenital  or  acquired 
syphilitic  lesion.  The  history  of  syphilis,  the  presence  of  other  syphi- 
litic symptoms,  the  greater  tendency  of  syphilitic  dactylitis  to  be  mul- 


*Emil  G.  Beck's  Method:  Bismuth  subnitrate  33  per  cent,  petrolatum  (yellow)  67  per  cent. 
The  paste  is  injected  slowly  by  means  of  a  strong  glass  syringe  with  a  conical  pointed  nozzle 
similar  in  shape  to  that  of  the  ordinary  urethral  syringe,  but  much  larger.  Its  prolonged  use 
may  give  rise  to  bismuth  poisoning! 


SPECIFIC    COMMUNICABLE   DISEASES 


473 


tiple  and  symmetrical,  and  the  ready  response  to  antisjphilitic  treat- 
ment usually  suffice  to  clear  up  the  diagnosis.  A  negative  Wasser- 
mann  reaction  and  a  positive  von  Pirquet  tuberculin  test,  and  the  coin- 
cidence of  tuberculous  lesions  elsewhere,  strongly  point  to  tuberculosis. 


Fig.  124. — Spina  ventosa. 

Early  constitutional  treatment  including  tuberculin  (q.v.),  and  pas- 
sive hyperemia  (see  p.  472)  are  very  efficient  curative  measures.  Con- 
servative surgery  (evacuation  of  pus  and  sequestra  and  injection  of 
bismuth  paste)  is  indicated  in  neglected  cases.  In  these  recovery  is 
slow,  usually  with  permanent  deformity. 

Nontuberculous  Osteomyelitis 

(  Osteitis  ;  Periostitis  ) 

The  term  osteomyelitis  refers  chiefly  to  inflammation  of  the  marrow 
of  the  bone,  but  includes  also  the  morbidity  of  the  bony  matrix  and 
periosteum,  which  at  one  period  or  another  participates  in  the  destruc- 
tive processes. 

Osteomyelitis  is  exceedingly  common  in  children  below  the  age  of 
puberty — before  completion  of  ossification  of  the  epiphyses  and  dia- 
physes — since  the  anatomic  peculiarities  of  the  circulation  in  growing 
bones  particularly  favor  its  development  on  slight  provocation.  The 
affection  is  observed  in  two  forms:  nontuberculous  and  tuberculous 
(see  p.  4^1).  Nontuberculous  osteomyelitis  most  frequently  affects 
the  long  bones  of  the  lower  extremity  (femur  and  tibia),  less  often  the 


474  DISEASES    OF    CHILDREN 

other  long  bones,  and  exceptionally  the  short  bones  of  the  body.  In 
most  instances  it  is  the  resnlt  of  infection  of  the  medullary  tissue  by 
pus  microbes,  especially  the  staphylococcus  and  streptococcus,  which 
enter  the  blood  from  suppurating  wounds  of  the  skin  (pustular  erup- 
tion!) or  from  pathologic  foci  in  the  respiratory  or  alimentary  tract. 
As  predisposing  and  contributory  causes,  we  may  mention  the  various 
contagious  and  infectious  diseases,  such  as  typhoid,  scarlatina,  measles, 
pneumonia,  sepsis  neonatorum,  etc.,  all  of  which  being  instrumental  in 
lowering  the  vitality  and  resistance  of  the  patient. 

Infection  of  the  medullary  tissue  once  established,  the  pathologic 
process  is  very  acute  and  violent.  If  left  alone,  the  inflammatory  proc- 
ess rapidly  goes  on  to  suppuration,  leading  to  loosening  of  the  perios- 
teum and  bone  necrosis  and  separation  of  the  diaphysis  from  its  epiphy- 
sis. If  the  patient  survives  and  the  inflammatory  process  subsides, 
there  is  a  separation  of  the  dead  bone  (sequestrum)  from  the  living. 
Unless  removed,  the  sequestrum  may  remain  an  everlasting  source  of 
irritation  and  suppuration.    . 

The  osteomyelitic  process  is  usually  ushered  in  by  a  chill,  rapid  rise 
of  temperature  and  pulse  and  other  symptoms  which  usually  accom- 
pany acute  suppurative  affections.  Before  the  appearance  of  the  local 
symptoms,  the  disease  is  very  apt  to  be  mistaken  for  a  pyemic  or  ty- 
phoidal  condition;  and  in  infants  unable  to  indicate  the  presence  of  lo- 
cal pain,  osteomyelitis  may  end  fatally  before  a  correct  diagnosis  has 
been  arrived  at.  Hence,  the  importance  of  a  careful  examination  of 
the  bony  system  in  all  febrile  affections  with  indefinite  source. 

In  the  newborn  the  onset  may  be  insidious.  There  may  be  signs  of 
omphalitis  or  the  umbilicus  may  already  be  healed.  For  some  obscure 
reason  the  infant  may  begin  to  cry,  especially  when  handled.  On  care- 
ful examination  it  is  found  that  the  baby  refuses  to  move  the  affected 
extremity  (see  Fig.  55). 

The  local  symptoms  of  osteomyelitis  are  pain,  tenderness,  swelling, 
redness,  synovitis,  epiphyseolysis,  and  loss  of  function. 

The  pain  is  excruciating,  boring  or  throbbing,  worse  at  night,  and 
increases  in  intensity  as  the  exudation  becomes  more  abundant.  Young 
children  are  rarely  capable  of  locating  the  exact  seat  of  the  pain,  but 
usually  refer  to  the  entire  affected  limb.  As  a  rule,  the  pain  disap- 
pears suddenly  with  the  escape  of  the  inflammatory  products  from  the 
interior  to  the  exterior  of  the  bone. 

Tenderness  on  pressure  can  be  detected  early,  and  is  most  severe 
where  the  inflammation  has  approached  nearest  the  surface  of  the  bone. 


SPECIFIC    COMMUNICABLE   DISEASES  475 

When  the  disease  is  located  deeply  in  the  medulla,  tenderness  can  he 
elicited  by  percussion. 

Swelling  and  redness  are  not  discernible  until  the  inflammation  has 
reached  the  periosteum.  Thrombophlebitis  and  edema,  however,  are 
often  early  symptoms. 

Synovitis  is  the  rule  where  the  disease  affects  the  epiphysis  as  well 
as  the  end  of  the  diaphysis.  The  intraarticular  effusion  is  at  first  ser- 
ous, the  result  of  vascular  disturbance,  but  as  the  suppurative  process 
in  the  bone  advances,  the  effusion  becomes  purulent  by  direct  exten- 
sion of  the  infection.  The  character  of  the  effusion  can  readily  be  de- 
termined by  exploratory  puncture. 

Epiphyseolysis,  or  separation  of  an  epiphysis  from  the  diaphysis,  is 
a  late  symptom,  or  rather  a  complication.  It  may  be  recognized  by 
soft  crepitation  between  the  separated  parts,  false  point  of  mobility  and 
displacement — signs  of  fracture. 

Loss  of  function  of  the  limb  is  invariably  present,  and  as  the  dis- 
ease advances  there  are  marked  contractures.  The  patient  instinctively 
assumes  such  postures  as  will  best  relax  the  muscles  and  ligaments  con 
nected  with  the  affected  area,  and  thus  prevent  painful  tension. 

These  symptoms,  if  closely  kept  in  view,  will  generally  avoid  errors 
in  the  diagnosis.  Typhoid  fever  can  readily  be  excluded  even  before 
the  development  of  local  symptoms  by  the  presence  of  marked  leuco- 
eytosis  in  osteomyelitis.  (For  differential  points  between  osteomyelitis 
and  arthritides,  see  p.  418.)  In  cases  of  doubt  a  roentgenogram  will  al- 
most invariably  settle  the  diagnosis. 

Treatment. — As  previously  indicated,  the  course  of  the  disease  va- 
ries w^ith  the  degree  of  infection  and  the  aggressiveness  of  the  treat- 
ment. Early  operative  interference  is  usually  followed  by  recovery 
in  the  great  majority  of  cases.  In  some  cases  the  infection  is  ex- 
tremely violent  and  death  occurs  vrithin  the  first  thirty-six  hours, 
before  or  notwithstanding  that  a  diagnosis  had  been  made  and  the 
appropriate  therapeutic  measures  employed.  The  great  danger  in 
osteomyelitis  is  the  tendency  to  venous  and  arterial  thrombosis  with 
secondary  embolism  and  abscesses  in  different  parts  of  the  body,  es- 
pecially in  the  lungs,  heart  and  kidneys. 

With  subsidence  of  the  acute  symptoms,  the  osteomyelitic  process 
is  not  always  at  an  end.  Transition  into  chronic  osteomyelitis  is  not 
uncommon.  (For  details,  see  a  treatise  on  surgery.)  Suppurating 
sinuses  leading  down  to  the  infected  sequestra  may  indefinitely  persist, 
and,  witb  occasional  improvement,  continue  to  undermine  the  vitality 
of  the  patient.  Amyloid  disease  of  various  viscera  (liver!)  may  form 
a  sequel  of  prolonged  suppuration. 


476  »  DISEASES    OF    CHILDREN 

Osteosarcoma 

Next  to  the  kidneys  (see  p.  582)  the  osseous  structures,  and  more 
particularly  the  long  bones,  form  the  most  frequent  seat  of  sarcoma  in 
children.  The  sarcomas  may  be  of  central  or  peripheral  origin.  The 
periosteal  variety  is  usually  more  rapid  in  growth  and  more  apt  to  in- 


Fig.  125. — Osteosarcoma  of  the  head  and  upper  third  of  sliaft  of  humerus  in  a  boy 
ten  years  old.     Note  also  early  metastasis  in  the  lungs. 

volve  the  bone  some  distance  from  the  joint.  The  etiology  is  still  ob- 
scure. In  the  majority  of  instances  we  can  elicit  a  history  of  trauma- 
tism at  the  seat  of  the  tumor  or  its  immediate  vicinity. 

In  the  early  stages  the  affection  may  be  mistaken  for  osseous  tuber- 
culosis, syphilis,  or  chronic  periostitis.     In  tuberculosis  the  swelling 


SPECIFIC    COMMUNICABLE   DISEASES 


477 


Fig.  126. — Enchondroma  of  upper  third  of  liumorus  in  a  child  eleven  years  old. 


is  more  gradual  in  its  development  and  most  frequently  attacks  the 
joints.  In  syphilitic  growths  we  usually  find  other  signs  of  syphilis 
and  a  positive  Wassermann  reaction.  Chronic  or  subacute  periostitis 
with  marked  thickening  of  the  periosteum  and  only  a  small  amount  of 
pus  can  readily   be   distinguished  from   osteosarcoma   by   a   careful 


478 


DISEASES   OF    CHIT.DREN 


Fig.  127. — Bone  cyst  in  shaft  of  humerus  causing  fracture  in  a  chilcl  six  years  old. 


Roentgen-ray  examination,  which  should  invariably  be  resorted  to  in 
eases  of  doubt.  Of  the  benign  neoplasms  chondroma  is  most  likely  to 
simulate  sarcoma,  but  chondroma  is  much  slower  in  growth  and  un- 
accompanied by  metastases — just  the  opposite  of  what  is  observed  in 
sarcoma.  In  one  case  under  our  observation  (Fig.  125)  sarcomatous  foci 
in  the  lungs  were  noted  six  weeks  after  the  earliest  signs  of  the  tumor 


SPECIFIC    COMMUNICABLE   DISEASES 


479 


in  the  humerus.  Constitutional  symptoms  usually  set  in  late  in  the 
course  of  the  disease — lience  the  reason  why  the  relatives  of  the  little 
patients  are  loath  to  accept  the  jDhysician's  advice  regarding  early 
radical  therapeutic  measures,  and  hence  also  the  extraordinarily  high 
mortality. 


Fig.  128. — Sarcoma  of  the  left  femur  in  a  girl  eight  years  old. 

Treatment. — Where  the  diagnosis  is  made  very  early,  i.  e.,  before  there 
are  any  evidences  of  metastases,  amputation  of  the  affected  limb,  as  high 
as  possible  above  the  seat  of  the  lesion,  may  save  the  patient 's  life.  The 
views  on  the  results  of  radium  treatment  are  too  conflicting  to  take  any 
chances  on  the  postponement  of  the  radical  operation  while  awaiting  the 
doubtful  outcome  of  the  radium  treatment.  All  other  methods  of  treat- 
ment thus  far  recommended  are  practically  futile. 


Scoliosis 

(  (Lateral  Curvature  of  the  Spine) 

In  contrast  to  the  aforementi9ned  tuberculous  deformity  (spondy- 
litis), scoliosis  is  not  tuberculous  in  nature.  As  a  rule,  it  is  habitual, 
or  static,  the  result  of  unequal  (one-side)  compression  of  the  inter- 
vertebral cartilages,  favored  by  atony  of  the  muscles  and  ligaments 
and  weakness  of  the  bones.  It  is  most  frequently  observed  in  school 
children,  especially  girls,  and  is  generally  ascribed  to  faulty  posture 
while  sitting  at  the  school  desk,  etc.,  and  to  the  habitual  carrying  of 
heavy  books  with  one  arm.  I  firmly  believe  that  a  great  many  cases  of 
so-called  habitual  lateral  spinal  curvatures  originate  during  early  in- 


480 


DISEASES   OF    CHILDREN 


fancy  in  connection  with  rachitis  {q.v.),  are  generally  overlooked  while 
the  deformity  is  slight,  and  are  detected  later,  at  a  time  when  the  de- 
formity does  and  would  gradually  get  worse,  whether  or  not  the  child 
goes  to  school.  Of  course,  this  view  does  not  preclude  the  fact  that 
faulty  posture  and  encumbrance  of  one-half  of  the  body  hasten  to  ag- 
gravate the  curvature.  Less  frequent  causes  are  obliquity  of  the  pelvis 
(e.  g.,  shortening  of  one  lower  extremity  from  birth  or  postnatal  dis- 
ease) ;  unilateral  paralysis  {e.  g.,  poliomyelitis,  progressive  muscular 
atrophy);  unilateral  immobility  of  the  thorax  {e.g.,  protracted  exten- 
sive  pleuritic   effusion   or   adhesions)  ;    and   unilateral   sinking   of   the 


Fig.  129. — Lateral  spinal  curvature;  second  degree. 

thorax  from  traumatism  or  operations  {e.g.,  multiple  fractures  of  ribs, 
resection  of  ribs  in  pyothorax).  Very  rarely  scoliosis  is  congenital  in 
nature,  when,  as  a  rule,  it  is  associated  with  other  congenital  malforma- 
tions, 

V 

Scoliosis  is  manifested  first  by  elevation  of  one  shoulder,  and  later 
by  prominence  of  one  hip  and  scapula  on  the  same  side  and  gradually 
increasing  convexity  of  the  spinal  column  and  side.  With  further  prog- 
ress of  the  deformity,  the  spinal  column  presents  two  curves,  in  the 


SPECIFIC    COMMUNICABLE   DISEASES  481 

shape  of  the  letter  S — the  primary  curve,  which  is  usually  in  the  dorsal 
region,  and  the  secondary  or  compensatory  curve,  usually  in  the  lumbar 
region.  Bad  cases  are  occasionally  complicated  also  by  lordosis,  de- 
formity of  the  thorax  and  displacement  of  the  heart  and  lungs,  but 
are  otherwise  free  from  constitutional  symptoms.  It  may  here  be  noted 
that  marked  lordosis  has  been  found  to  be  a  cause  of  orthotic  albumi- 
nuria (g.  V.) 


Fig.  130. — Lateral  spinal  curvature,  S-sliaped  scoliosis. 

Treatment. — Fortunately,  now^adays,  with  the  greater  attention  be- 
ing paid  to  the  general  health  of  children,  these  dreadful  deformities 
are  very  rarely  encountered.  Many  cases  come  under  the  care  of  the 
physician  in  the  first  stage  of  the  disease  which  ordinarily  yields  to 
massage,  calisthenics,  fresh  air,  ample  nutrition,  general  medicinal 
tonics,  and,  above  all,  removal  of  etiologic  factors.  Severer  forms  of  sco- 
liosis are  ©ften  corrected  by  a  plaster-of -Paris  or  celluloid  corset — worn 
continuously  for  several  months,  and  followed  by  massage  and  exercise  to 


482  DISEASES    OP    CHILDREN 

strengthen  the  weak  muscles.  Fixed  scoliosis  can  at  best  only  be  impeded 
in  its  further  progress,  but  the  damage  done  is  frequently  irrepara- 
ble. Hence,  the  importance  of  early  and  energetic  treatment,  and 
particularly  of  prophylactic  measures,  which  are  especially  effective 
in  habitual  scoliosis.  Here  the  school  physician  and  teacher  are 
offered  many  opportunities  to  merit  the  gratitude  of  the  community. 

Syphilis  Hereditaria  S.  Congenita 

(Syphilis  Embryonalis  or  Fetalis,  Syphilis  Neonatorum,  Syphilis 

Hereditaria  Tarda) 

Congenital  syphilis  is  due  to  a  specific  microorganism,  the  Spirochete 
pallida,  which  is  transmitted  to  the  embryo  or  fetus  either  through  the 
syphilitic  semen  (ex  patre),  ovule  (ex  matre),  or  maternal  blood  (at  any 
time  during  pregnancy). 

The  great  majority  of  syphilitic  embryos  or  fetuses  are  aborted.  The 
few  that  survive  may  pass  through  the  syphilitic  process  in  utero  (syph- 
ilis embryonalis  s.  fetalis),  or  may  maintain  a  good  state  of  health  dur- 
ing intrauterine  life,  be  born  in  apparently  perfect  health,  and  develop 
the  syphilitic  manifestations  soon  after  birth  {syphilis  neonatorum) ,  or 
not  until  several  years  after   (syphilis  hereditaria  tarda). 

Syphilis  Embryonalis  S,  Fetalis 

The  few  babies  who  survive  the  syphilitic  onslaught  during  intra- 
uterine life  and  are  born  at  or  near  full  term  present  a  ghastly  sight. 
They  are  shriveled  and  shrunken,  emaciated  and  disfigured,  with 
barely  a  spark  of  life  in  them.  They  are  often  asphj^xiated  and  usu- 
ally die  soon  after  birth.  Postmortem  examination  may  reveal  pro- 
nounced pathologic  changes  in  the  lungs  (fatty  degeneration  of  the 
pulmonary  alveoli — "pneumonia  alba")  ;  in  the  liver  (interstitial 
hepatitis)  ;  in  the  spleen  and  pancreas  (induration  and  gummatous 
deposit)  ;  in  the  kidneys  and  suprarenal  glands  (perivascular  infiltra- 
tion and  anemia  necrosis)  ;  in  the  thymus  gland  (cystic  degeneration 
and  abscess  formation)  ;  and  in  the  osseous  system  (epiphyseal  osteo- 
chondritis after  multiple  fractures).  The  skin  affection  consists 
chiefly  of  ''pemphigus  syphiliticus,"  a  bullous  eruption  on  a  dusky 
red,  slightly  elevated  base,  with  a  sanguinopurulent  content.  It  is 
usually  localized  on  the  palms  of  the  hands  and  soles  of  the  feet. 
Owing  to  extreme  tenderness  of  the  body  (sj^philitic  myositis'?)  the 
infant  is  very  restless,  and  cries  pitifully  when  handled. 


SPECIFIC    COMMUXICABLE   DISEASES 


483 


Fig.  131. — Congenital  sypliilis,  baby  three  weeks  old.  Note  excoriation  of  upper 
lip  from  the  ''snuffles."  The  navel  failed  to  heal  and  on  several  parts  of  the  body 
tlie  skin  was  exfoliating.     Note  also  peculiar  deformity  of  the  feet. 


Syphilis  Neonatorum 

As  previously  alluded  to,  the  infant  may  at  birth  appear  per- 
fectly healthy.  He  may  continue  to  thrive,  especially  if  fed  on  breast 
milk.  Before  long,  however — usually  after  from  about  one  week  to 
three  months^the  clinical  aspect  changes  materially.  The  baby  begins 
to  breathe  noisily,  especially  when  it  nurses,  "sniffles,"  becomes 
hoarse,  or  loses  its  voice  entirely.  The  nurse  or  the  weather  is  blamed 
for  the  baby's  "cold  in  the  head,"  until  examination  reveals  that 
the  syphilitic  coryza  is  associated  with  swelling  of  the  nasal  mucous 
membrane  and  occlusion  of  the  anterior  nares  by  a  seromucous  or  sero- 
sanguinolent  discharge  and  incrustation.  Inspection  of  the  mouth 
and  throat  often  discloses  grayish-white  patches  (plaques  muqueuses) 
upon  the  mucous  membrane  of  the  mouth  and  pharynx,  more  rarely 
papillomatous  vegetations,  and  occasionally  edema  glottidis,  which  lat- 
ter may  lead  to  fatal  termination.     Not  rarely  the  inflammation  of 


484 


DISEASES   OP   CHILDREN 


the  nasal  mucous  membrane  extends  to  the  nasal  periosteum  and  peri- 
chondrium, arresting  the  development  of  the  nasal  bones,  and  giving 
rise  to  the  peculiar  sinking  of  the  bridge  of  the  nose  which  is  generally 
designated  "saddle  nose."     This  is  rather  a  late  manifestation. 

The  syphilitic  manifestations  augment  from  day  to  day.  The  skin 
assumes  a  peculiar  light-  or  dark-yellow  (copper)  color,  is  dry  and 
hard  to  the  touch,  and  soon  becomes  covered  by  an  eruption  which 
is  typical  for  its  multiplicity  and  variability.  Almost  every  kind 
of  skin  disease  is  represented.  Papules,  vesicles,  pustules,  smooth 
and  scaly  patches,  tubercles,  wheals,  macules,  hemorrhagic  spots,  sim- 
ple redness,  scabs,  ulcers,  etc.,  vie  with  one  another  in  their  supremacy, 
and  rhagades   surround  the  different   external   orifices   of  the   body 


Fig.  132. — Syphilitic  pempliigus,  especially  marked  on  the   soles  of  the  feet.     Note 
also  condylomata  at  vagina  and  anus. 


(angles  of  the  eyelids  and  lips  at  the  alae  nasi,  anus,  labia  vaginae, 
etc.).  The  hairy  portions  of  the  body  also  participate  in  the  syphi- 
litic process.  The  hair  of  the  scalp,  eyebrows  and  eyelashes  rapidly 
fall  out  and  are  very  slow  in  returning.  The  nails  undergo  certain 
alterations,  such  as  thickening,  claw-like  deformities,  suppurative  in- 
flammation (onychitis)  and  exfoliation  (paronychia),  the  process  not 
rarely  extending  also  to  the  phalanges  (syphilitic  phalangitis,  q.v.). 
In  the  majority  of  cases  we  find  a  bullous  eruption  which  is  pathogno- 
monic of  grave  syphilitic  infection,  i.  e.,  'pemphigus  syphiliticus.  It  usu- 
ally sets  in  within  the  first  week  after  birth  as  flaccid,  yellow  or  brown- 
ish vesicles,  surrounded  by  an  areola  of  dry  epidermis  or  excoriation. 
The  buUffi  vary  in  size  from  a  pinhead  to  a  cherry,  burst  readily  and 
discharge  a  seropurulent  or  serosanguinolent  content.     They  are  dis- 


SPECIFIC    COMMUNICABLE   DISEASES 


485 


tributed  all  over  the  body,  but  particularly  over  the  palms  of  the  hands 
and  soles  of  the  feet — herein  differing  from  nonsyphilitic  pemphigus 
which  but  rarely  affects  these  parts.  In  consequence  of  the  inflamma- 
tory state  of  the  skin,  the  superficial  lymphatic  glands  are  more  or  less 
implicated,  the  swelling  often  persisting  long  after  disappearance  of  the 
primary  cause.  Enlargement  of  the  epitrochlear  glands,  just  above  the 
internal  condyle  of  the  humerus,  is  especially  common  and  of  diagnostic 
importance.  Special  mention  deserve  also  the  syphilitic  condylomata, 
especially  at  the  anus  and  female  genitals.  They  usually  begin  as  sim- 
ple papules  and  are  gradually  transformed  into  luxuriant  growths. 

With  the  aforementioned  clinical  findings  in  view,  it  requires  no 
sage  to  solve  the  problem  of  diagnosis.  Now,  if  the  physician  bases 
his  judgment  upon  the  symptoms  presented,  does  not  allow  himself  to 


Fig.    133. — Congenital   syphilis   in   eight-week-old   baby. 

rhagades,  and  exfoliation. 


Note    multiform    eruption, 


be  led  astray  by  spurious  histories  (omnis  syphiliticus  mendax!), 
but  goes  right  ahead  and  employs  suitable  antisyphilitic  measures 
(see  p.  494),  the  chances  of  rapid  improvement  and  ultimate  recovery 
are  very  good  indeed.  Otherwise,  the  syphilitic  process  often  violently 
runs  its  destructive  course,  attacks  one  structure  after  another,  one 
organ  after  the  other,  crippling  the  hapless  infant  for  life,  if  it  un- 
fortunately survives. 

The  osseous  system  hardly  ever  escapes  involvement.  As  in  fetal 
syphilis  (q.v.),  the  syphilitic  bone  affection  consists  principally  of 
an  osteochondritis  and  sometimes  caries  and  necrosis.  There  is  an 
overgrowth  of  the  cartilage  between  the  epiphyses  and  diaphyses  of 
the  long  bones,  often  giving  rise  to  painful  circular  swelling  in  the 
epiphyseal   region   and   separation   of  the   affected   limb    (spontaneous 


486 


DISEASES   OP    CHILDREN 


fracture),  with  consecutive  loss  of  i^ower  (Parrot's  pseudoparalysis). 
This  process  is  usually  (but  not  invariably)  unilateral,  herein  differing 
from  rachitis  in  which  the  epiphysitis  is  almost  always  bilateral. 
The  skull  presents  enlargements  (Parrot's  nodes)  of  the  parietal 
eminences  and  a  buffer-like  bossing  of  the  frontal  bone  which  is  gen- 
erally designated  "hot-cross-bun"  tumor.  Occasionally  tlie  frontal 
bone  appears  either  unduly  convex  and  prominent  (frons  Olympian) 
or  keel-shaped,  (Fig.  137)  with  a  central  ridge  and  lateral  flattening. 
These  syphilitic  manifestations  are  often  associated  with  craniotabes,  de- 
layed (or  premature)  closure  of  the  fontanelles  and  great  brittleness 
of  the  milk  teeth. 

The  liver  is  often  the  seat  of  cellular  infiltration  (interstitial  hepa- 
titis)  or  variously  sized  gummata,  rarely  large  enough  to  be  visible 


^Ib 

- 

^lltk 

^^p    |H 

^  IBIi^,^ 

A 

^ 

\.:JS- 

igggflBiii^ 

■--mp^  "■'i 

^ 

Fig.  134. — Congenital  syphilis  in  a  six-week-old  baby.     Note  maculopapular  eruption 
on  baby  and  on  mother's  hand. 


to  the  naked  eye.  The  liver  is  enlarged,  hard  and  uneven  to  touch, 
but  palpable  through  the  abdominal  wall  only  in  advanced  cases. 
Marked  syphilitic  changes  in  the  liver  frequently  give  rise  to  icterus, 
acholic  stools,  and  bile-colored  urine.  On  the  other  hand,  mild  forms 
of  the  disease  are  usually  entirely  free  from  symptoms. 

Next  to  the  liver,  the  spleen  is  most  prone  to  suffer  in  syphilis. 
It  is  enlarged  and  readily  palpable  through  the  abdominal  wall. 
Splenomegaly  being  of  so  common  occurrence  in  early  childhood, 
it  is  difficult  to  determine  how  much  of  this  phenomenon  is  due  to 
the  syphilitic  process  and  how  much  to  other  causes,  especially  rachi- 
tis. The  younger  the  infant  (under  six  months),  the  greater  the 
probability  of  the  perisplenitis  being  syphilitic   in  nature,   especially 


SPECIFIC    COMMUNICABLE   DISEASES 


487 


if  the  splenomegaly  is  associated  with  other  sj-philitic  symptoms,  such 
as  "Parrot's  nodes,"  condylomata,  and  ozena. 

Syphilis  of  the  pancreas  is  not  demonstrable  during  life,  but  it  has 


Fig.  135. — Syphilitic  dactylitis  of  right  index  finger  in  a  child  two  years  old. 
(Note  normal  left  hand.) 

repeatedly  been  proved — by  postmortem  examinations — that  the  pan- 
creas is  affected  in  a  way  very  similar  to  that  of  the  spleen. 

The  intestines  also  are  not  rarely  affected.     Intestinal  syphilis  is 


488  DISEASES   OP   CHILDREN 

manifested  chiefly  by  ring-shaped  indurations  of  the  muscles  and 
mucous  membrane,  leading  to  gradual  constriction  of  the  intestinal 
lumen.  The  pathologic  process  resembles  that  of  'Teyer's  patches," 
Clinically,  intestinal  syphilis  gives  rise  to  protracted  diarrhea,  often 
with  fatal  termination. 

Syphilitic  changes  (perivascular  cellular  infiltration;  gummatous 
deposit)  are  occasionally  met  also  in  the  kidneys  and  suprarenals  (pa- 
roxysmal hemoglobinuria;  nephritis),  in  the  heart  (symptoms  of  myo- 
carditis) ;  in  the  lungs  (pneumonia  Avith  slow  course;  spirochetes  in 
the  sputum),  in  the  thyroid  gland  (struma);  in  the  thymus  (cyst  or 
abscess);  in  the  testicles  (often  greatly  enlarged;  hydrocele;  arrested 
development),  and  in  the  ovaries  (demonstrable  postmortem;  some- 
times by  rectal,  bimanual  examination  during  life). 


Fig.  136. — Periosteal  syphilis  of  left  ulna  in  a  child  ten  years  o 


Arteritis  and  periarteritis,  gummatous  deposits  and  sclerosis  occa- 
sionally occur  in  the  brain  and  spinal  cord*  as  in  the  other  organs  of 
the  body,  and  the  concomitant  symptoms  vary  with  the  seat  of  the  le- 
sions. Chronic  meningitis  and  hydrocephalus  with  spina  bifida  are 
not  rarely  of  syphilitic  origin,  and  epilepsy,  idiocy,  local  paralysis  of 
the  extremities  and  of  the  eye  muscles,  blindness,  disseminated  sclero- 
sis and  tabes  dorsalis  have  been  occasionally  traced  to  congenital 
syphilis.  Also  cases  of  syphilitic  encephalitis  are  on  record.  The  re- 
semblance between  syphilis  of  the  nerve  system  and  tuberculosis  should 
not  be  lost  sight  of. 

As  already  suggested  the  diagnosis  of  syphilis  is  very  easy  when 
the  aforementioned  symptom  complex  is  in  full  bloom.  Cases,  how- 
ever, are  not  rarely  encountered  which  are  apt  to  test  the  skill  of 


*P.  C.  Jeans  (Jour.  Am.  Med.  Assn.,  Jan.  IS,   1921)   found  involvement  of  the  central  nerve 
system  in  one-third  of  the  cases  examined, 


SPECIFIC    COMMUNICABLE   DISEASES 


489 


even  the  best  diagnostician.  I  am  referring  especially  to  those  which 
either  run  a  very  latent  course  from  the  beginning,  or  do  so  after  a 
few  weeks'  antisyphilitic  treatment.  Every  bit  of  information  as  to 
the  past,  personal  ("snuffles,"  eruption,  etc.)  and  family  history  (mis- 
carriages; persistent  sore  throat  in  the  mother  or  father!)  should  be 
utilized  to  arrive  at  a  correct  conclusion.  Old  cracks  and  scars  at 
the  anus,  mouth,  nares,  etc.;  dark,  mottled  skin;  old  marks  of  healed 
ulcers  in  the  mouth  and  throat ;  persistent  ozena ;  intractible  inter- 
trigo, etc. ;  excessive  brittleness  of  the  milk  teeth  should  all  be  care- 
fully looked  into,  and  where  doubt  still  exists  the  patient  be  given  the 
benefit  of  the  doubt  and  actively  treated  for  syphilis — the  rapidity  of 


Fig.  137. — Sypliilitic  bal)y  eleven  montlis  old.     Note  keel-shaped  deformity  and  boss- 
ing of  greatly  distended  head.     Baby  is  also  mentally  deficient. 

response  to  treatment  at  the  same  time  serving  as  a  differential  point 
of  diagnosis  (therapeutic  test). 

Wherever  possible  laboratory  tests  should  supplement  ordinary 
clinical  examination.  Of  these,  Wassermann's  serum  diagnosis  of 
syphilis  and  Noguchi's  luetin  intradermic  test  are  deserving  of  spe- 
cial consideration.  In  cases  of  doubt,  the  parents  should  be  tested 
as  w^ell. 

With  establishment  of  the  diagnosis  of  syphilis,  the  remedies  to 
be  employed  to  eradicate  the  disease  fortunately  leave  no  room  for 
speculation.  The  treatment,  which  will  be  fully  outlined  in  the  sub- 
sequent pages  (see  page  494),  should  be  carried  out  energetically 
and  systematically  and  continued  until  apparently  every  vestige 
of  the  disease  has  been  completely  removed. 


490  DISEASES    OP    CHILDREN 

Inadequate  treatment  not  only  greatly  mars  the  prognosis  of  syph- 
ilis as  to  life  and  recurrences,  but  only  too  often  is  responsible  for 
the  development  of  the  symptom  complex  which  is  generally  described 
as  "parasyphilis. "  This  group  of  syphilitic  manifestations  (syphilitic 
cachexia)  consists  of  extreme  debility,  marasmus  (especially  in  the 
artificially  fed)  ;  profound  anemia  (pseudoleukemia),  obstinate  gas- 
trointestinal and  bronchial  catarrh,  otitis  (deafness),  disposition  to 
rachitis,  cretinism  and  idiocy,  and  lowered  power  of  resistance  to 
divers  acute  infectious  diseases.  While  the  mortality  of  the  carefully 
treated  syphilitics  is  comparatively  small,  those  who  are  carelessly 
managed  often  succumb  to  intercurrent  diseases,  even  of  the  most 
trifling  character,  not  rarely  die  suddenly  without  apparent  cause, 
and  if  they  survive,  remain  decrepit  for  life,  and  a  source  of  horrible 
misery  to  future  generations. 

Syphilis  Hereditaria  Tarda  s.  Lata 

Late  hereditary  syphilis  attacks  the  offspring  of  syphilitic  parents  at 
any  period  between  early  childhood  and  adolescence.  The  children 
thus  affected  may  or  may  not  have  shown  manifestations  of  congeni- 
tal syphilis  during  intrauterine  life  or  soon  after  birth.  The  symptoms, 
however,  are  more  pronounced  in  those  who  had  been  treated  inade- 
quately or  not  at  all.  Late  hereditary  syphilis  essentially  corresponds 
to  the  tertiary  stage  of  acquired  syphilis.  Like  the  latter  it  shows 
a  predilection  for  the  eyes  and  osseous  system;  but  no  structure  or 
organ  of  the  body  is  free  from  its  destructive  effects. 

As  will  be  presently  demonstrated,  the  lesions  of  late  hereditary 
syphilis  may  be  numerous  and  grave,  but  not  always  strictly  pathog- 
nomonic of  this  disease.  There  is,  however,  one  group  of  syphilitic 
manifestations,  which,  if  present,  invariably  betrays  the  existence  of 
a  syphilitic  taint. 

This  symptom  complex  is  generally  described  as  the  "triad  of  syph- 
ilis" and  consists  of  the  folloAving  manifestations: 

1.  The  So-called  Hutchinson  Teeth. — The  characteristic  teeth  of 
syphilis  are  the  two  upper  central  incisors  of  the  permanent  set.  The 
teeth  are  chalky,  ill-developed,  small,  and  irregularly  placed.  They 
taper  from  the  free  border  to  the  base,  hence  the  term  "screw-driver 
teeth,"  and  present  a  broad,  semilunar  notch  in  the  center  to  the 
edge.  They  should  not  be  confounded  with  the  brittle  and  decayed 
milk  teeth  observed  in  infantile  syphilis  or  rickets,  and  the  irregu- 
larly implanted  teeth  associated  with  deformed  palate  or  dental  arches. 


SPECIFIC    COMMUNICABLE   DISEASES  491 

2.  Interstitial  Keratitis. — This  almost  invariably  symmetrical  af- 
fection begins  Avith  corneal  haziness  which  rapidly  increases  until  the 
entire  cornea  is  in  a  condition  of  partial  opacity  resembling  '*  ground- 
glass."  It  is  associated  with  congestion  of  the  ciliary  region  and 
slight  inflammation  of  the  conjunctiva,  and  in  severe  forms  of  the 
disease,  with  iritis,  retinitis  and  choroiditis.  In  addition  to  the  cor- 
neal gray-colored  patches,  abruptly  margined,  creseentic  patches  of 
salmon  tint  are  often  present  on  the  corneal  surface,  this  sign  of 
vascularity  not  rarely  spreading  over  the  whole  cornea  and  giving 
rise  to  a  deep  plum  tint  of  purple  redness.  Excessive  lacrimation 
and  photophobia  prevail  from  the  start,  in  marked  cases  reducing 
the  patient  to  a  state  of  practical  blindness.  The  disease  runs  a  very 
slow  course,  from  about  three  months  to  a  year  or  longer,  and,  when 
it  subsides,  leaves  behind  more  or  less  marked  corneal  opacity  and 
visual  impairment. 

3.  Deafness. — This  condition  is  not  accompanied  by  any  inflamma- 
tory symptoms.     It  is  caused  by  syphilitic  involvement  of  the  laby- 


Fig.   138. — Syphilitic   "  HuteJiinson  teeth."     Note   semilunar   notches   in   central  in- 
cisors. 

rinth  (often  deafness  of  both  ears).  The  deafness  very  rarely  clears 
up  spontaneously  and  entirely.  On  the  contrary,  even  under  active 
treatment  defective  hearing  is  the  rule.  This  peculiar  form  of  deafness 
often  precedes  or  follows  the  attack  of  keratitis  and  is  gradual  in 
development. 

The  hone  lesions  of  late  syphilis  consist  of  an  osteoperiostitis,  or  soft 
gummatous  periostitis,  especially  of  the  tubular  and  cranial  bones. 
The  most  frequent  seat  of  the  disease  is  the  tibia,  then  follow  the 
ulna  and  radius,  the  humerus,  femur,  clavicle,  the  bones  of  the  skull, 
the  phalanges  and  sternum.  Syphilis  of  the  shaft  of  the  tibia  usually 
gives  rise  to  a  characteristic  *' saber-shaped"  deformity  of  the  tibia, 
the  so-called  "tibia  en  lame  de  sabre."  It  differs  from  the  rachitic 
deformity  of  the  tibia  by  its  crest  being  rounded  (in  rickets  it  is 
sharpened)  and  its  internal  and  external  surfaces  convex  (in  rickets 
they  are 'flat  or  concave). 

The  cranial  bones  are  affected  in  a  manner  similar  to  that  of  syph- 


492 


DISEASES    OF    CHILDREN 


ilis  neonatorum.  (See  page  483.)  Ulceration  of  the  soft  palate  and 
throat,  and  perforation  of  the  hard  palate  and  nasal  bones  with  sec- 
ondary "saddle-shaped"  deformity  of  the  nose  are  of  common  oc- 
currence. 

Syphilis  of  the  phalanges  (syphilitic  dactylitis)  is  characterized  by 
a  puffy,  fusiform,  or  spindle-shaped  swelling.  It  affects  the  fingers 
more  often  than  the  toes.  The  inflammation  may  begin  either  in  the 
connective  tissue  and  ligaments  or  in  the  periosteum  and  bone.  If 
let  alone  the  disease  progresses  rapidly  and  leads  to  protracted 
osteomyelitis  with  ankylosis,  shortening  and  permanent  deformity  of 
the  affected  parts.     Syphilitic  dactylitis  differs  from  the  tuberculous 


Fig.  139. — Gumma  of  the  right  parietal  bone  in  an  eight-year-old  boy  suffering  from 

syphilis   hereditaria   tarda. 

variety,  which  it  greatly  resembles,  by  its  bein^  less  common,  often 
symmetrical  and  accompanied  by  other  syphilitic  lesions.  The  tuber- 
culin and  Wassermann  reactions  are  decisive  in  the  diagnosis. 

Occasionally  the  joints  participate  in  the  syphilitic  process,  but 
the  affection  is  rarely  of  serious  nature.  It  essentially  consists  of 
a  recurrent  synovitis  with  thickening  and  ankylosis,  and  may  readily 
be  mistaken  for  articular  rheumatism.  The  absence  of  fever  and 
redness  and  the  history  of  syphilis  usually  clear  up  the  diagnosis. 

The  skin  sometimes  presents  subcutaneous  gummata  which,  when 
neglected  have  a  great  tendency  to  break  down  and  to  form  large 
phagedenic  ulcers.  They  are  most  frequently  met  with  on  the  face 
and  upper  part  of  the  thighs  or  legs.     They  promptly  yield  to  ener- 


SPECIFIC    COMMUNICABLE   DISEASES 


493 


getic  antisj'philitic  treatment — a  feature  to  be  borne  in  mind  in  the 
differential  diagnosis  between  syphilitic  and  tuberculous  ulcers. 

The  lymphatic  system  and  the  viscera,  especially  the  liver  and 
spleen  rarely  fail  to  show  late  syphilitic  manifestations.  The  latter 
are  essentially  identical  with  those  described  in  connection  with  con- 
genital syphilis  neonatorum.    (See  p.  476.) 

Finally,   mention  may  be  made   of  the   tendency   of  late   syphilis 


Fig,  140. — Syphilitic  osteoperiostitis  of  the  til)ia% — "  Saber-shapc-def ormity, " — and 
of  the  nasal  bones,  with  high  degree  of  rachitis. 

to  arrest  the  development  of  the  child's  body  and  mind.  Dwarfism 
and  infantilism  are  not  rarely  traceable  to  this  baleful  cause.  Indeed, 
appreciating  the  gravity,  multiplicity  and  complications  of  the  syph- 
ilitic lesions  it  is  rather  surprising  that  the  aforementioned  bodily 
and  mental  deteriorations  are  not  more  rampant. 

Notwiihstanding  the  apparent  explicitness  of  the  symptomatology, 
the  diagnosis  of  late  hereditary  syphilis  is  by  no  means  a  simple 


494  DISEASES   OF    CHILDREN 

proposition.     It  is  especially  difficult  in  cases  complicated  by  inter- 
current diseases,  e.  g.,  tuberculosis  or  rickets. 

The  specific  history;  the  simultaneous  occurrence  of  lesions  in  va- 
rious parts  of  the  body;  the  tendency  of  the  bone  lesions  to  be  sym- 
metrical ;  the  appearance  of  the  manifestations  very  frequently  in  the 
midst  of  apparently  perfect  health;  and,  finally,  the  quick  response 
to  antisyphilitic  treatment  are  more  or  less  decisive  in  the  diagnosis. 
Of  course,  all  doubt  is  removed  by  positive  microscopic  or  bacteriologic 
findings,  especially  serum  diagnosis. 

Acquired  Syphilis 

The  newborn  may  acquire  syphilis  either  intrapartum,  by  coming 
into  contact  with  a  chancre  in  the  parturient  canal,  or  while  nursing 
at  the  breast  of  a  woman  (mother  or  wet-nurse)  in  the  contagious 
state  of  syphilis.  The  disease  may  further  be  acquired  by  infants  and 
older  children  practically  in  the  same  manner  as  by  adults.  It  is  well 
to  remember  that  the  newborn  with  secondary  symptoms  of  syphilis 
may  transmit  the  disease  to  healthy  people  through  fondling,  the  use 
of  articles  coming  in  contact  with  syphilitic  lesions,  etc.  I  have  in 
mind  two  older,  previously  healthy  brothers,  who  have  in  this  manner 
acquired  syphilis  from  a  syphilitic  newborn. 

The  course  of  acquired  syphilis  in  children  is  identical  with  that 
observed  in  adults,  except  that  it  is  prone  to  be  more  rapid  and 
violent. 

The  primary  lesion  (chancre)  is  usually  found  in  the  child's  mouth 
(from  kissing  or  sucking  of  infected  nipples),  or  on  the  perineum  (from 
washing  of  baby's  buttocks  with  infected  hands).  Occasionally  the 
primary  sore  is  on  the  penis,  as  a  result  of  infection  during  ritual 
circumcision. 

Treatment.— The  treatment  of  syphilis  is  alike  in  both  forms  of 
the  disease — inherited  (early  and  late)  and  acquired.  It  should  be 
begun  as  soon  as  the  diagnosis  has  been  established.  Temporizing 
is  often  fatal.  Mercury  in  some  form  is  the  only  remedy  that  is 
certain  in  its  results,  and  should  be  administered  continuously  until 
every  vestige  of  the  disease  has  apparently  disappeared,  and  then  given 
at  intervals  of  from  two  to  six  weeks  for  a  total  period  of  from  two 
to  three  years.  Calomel  is  the  preparation  par  excellence.  One-tenth 
to  ^4  grain  twice  (to  an  infant)  or  thrice  daily  (to  an  older  child) 
will  usually  suffice.  Now  and  then  we  may  also  employ  sodium  iodide 
(1/2  grain  for  every  year  of  the  child's  age)  three  times  a  day,  or  syrup 
of  iodide  of  iron  (5  drops  for  an  infant  under  one  year,  10  drops  for 
two  years,  and  15  drops  for  over  five).     To  hasten  saturation  of  the 


SPECIFIC    COMMUNICABLE   DISEASES  495 

system  with  the  mercury,  we  may,  in  addition,  resort  to  mercury  iu- 
unctions.  From  10  to  30  grains  of  mercurial  ointment  may  be  rubbed 
in  once  a  day  alternately  into  the  axilla,  groin,  abdominal  wall,  calf 
muscles,  and  loins.  To  prevent  excessive  salivation  the  oral  cavity 
should  be  washed  twice  daily  with  a  2  to  5  per  cent  solution  of  chlorate 
of  potash  or  tincture  of  myrrh.  Syphilitic  ulcers  should  be  cauterized 
with  nitrate  of  silver  solution  (3  per  cent  to  10  per  cent).  Keratitis 
calls  for  local  use  of  atropine  sufficient  to  keep  the  pupils  widely 
dilated,  hot  poultices  (by  means  of  moist  hot  cloths),  occasional  dust- 
ing of  calomel  over  the  corneal  ulcers,  protection  from  bright  light 
(dark  room  or  smoked  glasses),  and,  of  course,  internal  administration 
of  mercury  and  the  iodides.  The  great  majority  of  cases  of  osteitis 
yield  promptly  to  constitutional  treatment,  but  where  the  necrosis 
is  pronounced  the  management  must  follow  ordinary  surgical  lines. 
Persistent  condylomata  will  rapidly  disappear  after  a  few  applications 
of  a  5  per  cent  salicylic-resorcin-collodion  solution,  or  occasional 
painting  with  caustics.  Onychia  and  paronychia  should  be  treated  by 
local  bichloride  baths  (1:2000),  once  or  twice  daily,  and  dusting  with 
calomel  1  part,  gum  arable  1  part,  and  stearate  of  zinc  10  parts.  In- 
durated lymph  glands  usually  yield  to  potassium  iodide  ointment, 
while  suppurating  glands  require  surgical  interference. 

The  general  health  of  the  patient  should  not  be  lost  sight  of.  Other 
conditions  being  favorable,  a  syphilitic  mother  should  nurse  her 
syphilitic  child.  This  being  impossible,  the  infant  should  be  put  on 
properly  modified  cow's  milk,  or  on  the  breast  of  a  wet-nurse,  who 
has  emerged  from  an  attack  of  syphilis  without  serious  consequences. 
In  older  children  also  particular  attention  should  be  paid  to  good  nu- 
trition. The  tendency  of  rickets  complicating  syphilis  should  be 
borne  in  mind.  Hydrotherapy,  plenty  of  fresh,  pure  air,  and  general 
tonics  are  essential  to  success. 

Pediatrists  are  not  particularly  in  favor  of  salvarsan  in  children,  be- 
cause it  is  difficult  to  administer  it  in  young  babies,*  and  is  not  at 


*The  Lowy  Laboratory  gives  the  following  directions  for  the  administration  of  neoarsphen- 
ainine  in  infants  and  older  children: 

Wrap  the  child  in  a  blanket  (as  for  intubation),  lay  it  on  the  table  on  its  side  and  place  a 
very  low  pillow  under  its  head  so  as  to  have  the  head  level  with  the  line  of  the  spine;  then 
sterilize  the  side  of  the  neck.  The  external  jugular  vein  will  be  found  by  drawing  a  straight 
line  from  the  outer  portion  of  the  lobe  of  the  ear  directly  to  middle  of  the  clavicle.  By  placing 
the  little  finger  or  a  pencil  a  little  above  the  clavicle  directly  in  line  with  the  clavicle,  and  exert- 
ing gentle  pressure,  the  jugular  will  become  distended  so  as  to  become  visible.  Having  properly 
distended  the  vein,  take  a  20  gauge  needle,  insert  it  at  the  lower  portion  of  the  jugular  vein 
about  one-half  inch  above  the  place  where  pressure  is  being  exerted.  With  a  firm  push  insert 
the  needle  into  the  vein,  care  being  taken,  however,  that  the  point  of  the  needle  is  towards  the 
heart.  When  the  blood  begins  to  flow,  without  attempting  td  remove  the  needle,  apply  the 
adapter  supplied  with  Solution  Arsphenamine-Lowy,  and,  permit  solution  to  flow  in  very  slowly, 
the  dose  being  20  c.c.  per  thirty  pound  body  weight.  It  is  sometimes  advisable  to  measure  out 
the  quantity  desired  into  the  barrel  of  the  syringe  and  use  the  barrel  of  the  syringe  similar  to 
a  gravity  container,  as  in  that  fashion  the  amount  ttsed  can  be  accurately  gauged.  Five  to  six 
injections  should  be  given  at  one  week  intervals.  It  may  be  necessary  to  give  a  series  of  these 
injections. 


496  DISEASES   OF   CHILDREN 

all  free  from  serious  consequences,  and,  furthermore,  because  it  shows 
no  superiority  over  the  mercury  and  iodide  treatment.  The  dosage 
of  salvarsan  or  noosalvarsan  is  0.005  to  0.01  gram  per  kilo  of  body 
weight.  It  should  be  administered  once  or  twice  a  week  until  the  Wasser- 
mann  reaction  proves  negative  on  several  examinations.  Syphilitic 
children  should  be  kept  under  observation  for  several  years  after  ap- 
parent recovery  from  the  disease. 

J.  A.  Fordyee*  and  I.  Rosen  combine  mercury  with  neoarsphenamine 
treatment.  The  latter  is  administered  intramuscularly,  half  of  the  solu- 
tion into  each  buttock,  in  the  following  doses  at  weekly  intervals :  0.075 
gm.  for  infants  from  3  to  8  weeks ;  0.1  gm.  from  2  to  6  months ;  0.15  gm. 
from  6  to  12  months ;  0.15  to  0.2  gm.  from  1  to  2  years.  These  doses  are 
employed  in  courses  of  from  6  to  8,  followed  by  rest  periods  of  from  4  to 
6  weeks. 

Frambesia 

(Yaws) 

Frambesia  is  caused  bj^  the  Treponema  pertenue,  a  slender  spirillum 
resembling  the  spirocheta  of  syphilis.  The  mode  of  conveyance  of  the 
disease  is  still  obscure,  but  probably  occurs  by  direct  contact.  In 
endemic  countries  (Philippine  Islands,  Ceylon,  Tropical  Africa,  Fiji, 
and  Samoa)  this  affection  is  quite  prevalent  among  young  children. 
One  attack  seems  to  confer  permanent  immunity. 

The  incubation  period  lasts  from  two  to  five  weeks,  in  the  last  few 
days  manifesting  itself  by  irregular  temperature,  muscular  and  articu- 
lar pain,  anorexia  and  lassitude.  About  a  week  later  a  papule  makes 
its  appearance  which  soon  turns  into  a  pustule,  often  perforated  by  a 
hair.  On  further  growth  this  primary  lesion  assumes  a  raspberry-like 
appearance.  The  secondary  eruption  develops  within  from  one  to 
three  months  after  the  primary  lesion,  like  the  latter  is  preceded  by 
general  febrile  symptoms,  and  like  it  also  consists  of  cauliflower-like 
excrescences  which  may  be  distributed  throughout  various  parts  of  the 
body  but  more  especially  over  the  face  and  neck  and  anal  and  genital 
regions.  The  lesions  may  recur  at  short  or  long  intervals  for  years, 
especially  if  left  untreated.  Bone  changes,  especially  in  the  feet  and 
hands  (dactylitis)  are  quite  common;  and  as  a  result  of  extensive 
ulcers  we  occasionally  meet  with  serious  deformities  of  the  hands  and 
feet.  Ulceration  and  necrosis  of  the  frontal  bone  also  is  not  infrequent. 
Cases  presenting  these  symptoms  may  readily  be  mistaken  for  syphilis. 
Indeed,  before  the  discovery  of  the  Wassermann  reaction  some  authors 
were  inclined  to  look  upon  yaws  as  a  type  of  syphilis.  This  view  has 
proved  erroneous,  for  it  has  frequently  been  shown  that  a  patient  with 


*Jour.  Am.  Med.  Assn.,  Nov.  20,   1920. 


SPECIFIC    COMMUNICABLE   DISEASES  49? 

yaws  may  contract  syphilis  and  vice  versa.  However,  while  frambesia 
is  a  disease  sui  generis,  it  has  been  found  like  syphilis  to  respond  to 
intravenous  injection  of  neosalvarsan.  In  the  way  of  prophylaxis,  it  is 
important  to  avoid  solution  of  continuity  of  the  skin  when  handling 
patients  suffering  from  the  yaws,  and  to  protect  all  abrasions  by  means 
of  collodion,  adhesive  plasters  and  antiseptics. 

Leprosy 

Leprosy  is  an  infectious  disease  pursuing  a  chronic  course  due  to 
an  acid-fast  bacillus,  the  Bacillus  leprce  (discovered  by  Hansen  of 
Bergen  in  1871)  which  resembles  the  tubercle  bacillus.  It  is  an  un- 
common disease,  especially  in  sanitary  countries.  In  the  following 
table  Dr.  Heiser  gives  an  approximate  estimate  of  the  proportion  of 
lepers  to  the  population  of  different  countries. 

Japan  1  in  1000. 

Philippine  Islands  1  in  1400. 

India  1  in  2000. 

United  States  1  in  100000. 

New  Zealand  1  in  200000. 

Australia  1  in  200000. 
The  exact  mode  of  transmission  of  the  disease  is  still  unknown.  It 
is  not  congenital  in  character.  Fifty  children  born  of  leprous  parents 
at  the  Culion  Leper  Colony  showed  no  traces  of  leprosy  at  birth.  Some 
of  them,  however,  contracted  the  disease  later,  by  remaining  in  close 
contact  with  their  mothers.  Kitasato  maintains  that  over  7  per  cent  of 
the  children  of  lepers  sooner  or  later  acquire  the  disease.  The  incuba- 
tion period  is  of  variable  duration,  in  some  instances  several  years. 
Once  the  disease  is  established  it  is  found  that  the  bacilli  entering  the 
human  body  have  multiplied  enormously  and  become  enclosed  in 
plasma  cells  (lepra  cells). 

We  generally  distinguish  three  varieties  of  the  disease,  as  follows : 
1.  Anesthetic  Leprosy. — In  this  form  the  anatomic  changes  (infiltra- 
tion) occur  principally  in  the  nerve  system.  It  ordinarily  begins  with 
shooting  pain,  particularly  in  the  ulnar  and  peroneal  nerves,  flushing, 
erythema,  of  the  face,  glossy  skin  and  muscular  twitching.  It  is  soon 
followed  by  anesthesia  of  large  surfaces  of  the  body.  With  further 
progress  of  the  disease  and  consecutive  destruction  of  the  nerves,  trophic 
changes,  especially  of  the  extremities  soon  supervene,  accompanied  by 
ulceration  of  the  affected  structures  which  fail  to  heal  and  gradually 
undergo  total  destruction  (amputation  of  terminal  extremities).  This 
process  is  6ften  associatetd  with  marked  contractures,  e.  g.,  of  the  thumb 
and  fingers  {main  en  griff). 


498 


DISEASES    OF    CHlLDREISr 


2.  Tubercular,  Nodular  or  Hypertrophic  Leprosy. — This  variety  is 
usually  ushered  in  by  a  macular  eruption  and  febrile  disturbance.  At 
first  the  ears,  nose  and  face  are  infiltrated.  Gradually  the  eruption  as- 
sumes a  nodular,  tubercular  consistency,  resembling  a  crop  of  red  po- 
tatoes, and  spreads  all  over  the  body.    In  late  stages  the  contour  of  the 


Fig.  141. — Case  of  leprosy  in  a  child  sliowiiig  infiltratioTi  especially  in  ears,  lips 
and  hands.  Leprous  nodules  in  the  left  arm.  Example  of  tubercular,  nodular,  hyper- 
trophic leprosy.  (After  J.  C.  DaCosta,  Jr.,  Handbook  Medical  Treatment,  F.  A. 
Davis  Co.) 

face  resembles  that  of  a  lion.  Infiltrations  occur  also  in  the  larynx, 
lungs  and  eyes,  but  perforating  ulcers  are  not  as  common  as  in  the  anes- 
thetic variety. 


SPECIFIC    COMMUNICABLE   DISEASES  499 

3.  Mixed  Leprosy,  is  charaeterized  by  the  intermingling  of  the  princi- 
pal symptoms  of  the  two  other  varieties  of  the  disease,  and  is  the  most 
common  type  met  with  in  leper  asylums. 

The  diagnosis  presents  no  difficulties  in  advanced  cases,  bnt  in  the 
early  stages  leprosy  may  be  mistaken  for  lupus  or  syphilis,  and  in 
doubtful  cases  it  may  become  necessary  to  search  for  the  acid-fast  lepra 
bacilli  in  the  scrapings  of  the  affected  tissues,  in  order  to  arrive  at  a 
prompt  decision. 

Treatment. — Isolation  and  segregation  of  the  patient  in  a  leper  hospi- 
tal until  at  least  two  years  after  total  disappearance  of  the  clinical  mani- 
festations as  well  as  the  microscopic  findings.  Even  then  lepers  should 
be  kept  under  surveillance.  Persons  with  open  wounds  should  not  come 
in  close  contact  with  lepers.  The  active  treatment  consists  of  hypo- 
dermic injections  of  the  following  preparation   (Unna's  modification)  : 

IJ     Cliaulmoogra  oil  (obtained  from  the  seeds  of  gynocardia  odorata)* 

Camphorated  oil  aa   30-0 

Eesorcin  2.0 

Mix  and  dissolve  with  aid  of  heat  and  filter. 
Sig. — Five  to  fifteen  drops  hypodermically   onee  a    week.     Quicker   results 

are  obtained  when  the  injections  are  made  in  the  infiltrated  areas. 

In  eases  where  severe  reactions  follow  {e.g.,  fever,  cardiac  distress), 
the  dose  may  be  reduced  in  quantity  but  given  more  frequently.  Pro- 
longed hot  bicarbonate  of  soda  baths  act  beneficially.  Ulcerations  and 
other  symptoms  are  treated  according  to  indications. 

Pestis  Bubonica 

(Bubonic  Plague,  Black  Death) 

The  history  of  this  dreadful  scourge  is  traceable  to  the  old  Bible. 
In  recent  years  it  raged  in  China  and  India  and  sporadic  cases  were 
observed  in  port  cities  of  Italy,  Scotland  and  England  as  well  as  those 
of  South  America  and  the  United  States  (New  Orleans,  Pensacola, 
Galveston,  Seattle  and  San  Francisco).  Most  recently  several  cases  of 
the  plague  have  been  reported  from  Mexico  and  Texas. t  The  disease  is 
spread  mainly  through  infected  rats,  by  bites  of  rat-fleas.  It  is  caused 
by  the  Bacillus  Pestis,  which  was  discovered  by  Yersin  and  Kitasato  in 
1894  and  is  regularly  found  in  the  circulating  blood  of  plague  patients  as 
well  as  in  the  sputum  (pneumonic  plague),  enlarged  glands,  spleen  and 
other  organs  of  the  body. 


*Walker  and  Sweeney  (Jour.  Infect.  Dis.,  26,  1920)  have  recently  demonstrated  that  this  oil 
contains  bactericidal  substances  that  are  about  one  hundred  times  more  potent  than  phenol,  and 
that  its  acticm  is  specific  for  the  acid-fast  group   of  bacteria. 

tAnalysis  of  26  cases  of  Beaumont  and  Galveston,  by  M.  D.  Levy  (Texas  State  Journal, 
October,    1920). 


500  DISEASES   OF    CHILDREN 

The  incubation  period  ordinarily  lasts  two  or  three  days,  but  oc- 
casionally may  be  of  much  longer  duration.  The  attack  is  ushered  in 
with  chills,  high  temperature,  mental  depression,  delirium  and  often 
convulsions.  These  symptoms  are  soon  augmented  by  the  appearance 
of  painful  swelling  of  the  inguinal  (buho)  and  axillary  glands,  pe- 
techiae  (hence  the  name  of  ''black  death")  and  occasionally  internal 
hemorrhages,  and  in  fatal  cases  muttering  delirium  and  coma.  Septi- 
cemic plague  with  early  prostration,  vomiting  and  dysentery  and  low 
temperature,  ends  fatally  even  before  the  appearance  of  the  bubo,  while 
mild  cases,  pestis  minor,  may  not  be  ill  enough  to  go  to  bed  and  can  only 
be  diagnosed  by  the  finding  of  the  bacilli  in  the  glands  or  blood.  In 
about  ten  per  cent  of  cases  the  plague  appears  in  the  form  of  pneumonia 
(pneumonic  plague).  The  symptomatology  of  this  type  of  the  disease 
greatly  resembles  the  so-called  epidemic  influenza  pneumonia,  character- 
ized by  extreme  dyspnea,  profuse  bloody  expectoration,  cyanosis  and 
heart  failure,  and  is  almost  invariably  fatal.  It  has  often  been  observed 
that  patients  surviving  six  days  show  a  tendency  to  recover,  although 
convalescence  is  slow  and  not  rarely  marred  by  complications.  The 
glands  usually  suppurate  and  either  break  spontaneously  or  have  to  be 
incised.  The  mortality  as  a  whole  ranges  between  60  and  90  per  cent. 
Postmortem  examination  usually  reveals  involvement  of  the  spleen, 
lungs,  liver,  heart  and  kidneys,  all  more  or  less  studded  with  small,  con- 
fluent hemorrhages. 

Treatment. — Prophylaxis  is  most  essential.  Rats  and  their  breeding 
places  should  be  promptly  destroyed.  All  patients  should  be  strictly 
isolated,  and  persons,  as  well  as  animals,  coming  in  contact  with  them 
quarantined.  Ships  carrying  suspicious  cases  should  be  detained.  In- 
fected buildings  should  be  fumigated  and  if  possible  destroyed. 

Prophylactic  vaccines  of  Haffkine  and  others  administered  hypo- 
dermically  in  the  arm  twice  at  an  interval  of  ten  days  affords  sure  im- 
munity against  the  plague  for  about  three  months.  It  has  recently  been 
shown  also  that  Haffkine 's  vaccine  in  combination  with  Tersin's  serum 
(live  bacilli  injected  into  a  horse)  is  potent  to  reduce  the  mortality  to 
less  than  20  per  cent.  Similar  results  are  claimed  for  Lustig's  serum 
with  antitoxic  properties  (obtained  by  immunizing  horses  to  the  endo- 
toxin of  the  bacillis  pestis) .  The  serums  are  given  intravenously  as  well 
as  in  the  affected  glands. 

Aside  from  the  specific  treatment  special  attention  is  devoted  to  the 
heart,  nutrition  and  general  comfort  of  the  patient. 

Physicians  and  attendants  of  plague  patients,  especially  of  the  pul- 
monary type,  should  wear  face  masks  of  canton  flannel  with  eyes  of  cel- 
luloid. 


CHAPTER  VIII 

DISTURBANCES  OF  METABOLISM 

Marasmus,  Athrepsia,  Infantile  Atrophy 

(Fed  atrophy) 

The  nature  of  this  appalling  infantile  wasting  is  still  shrouded  in 
mystery.  It  is  apparently  only  a  functional  disorder,  a  form  of  in- 
testinal autointoxication,  arising  from  nonassimilation  of  the  food 
consumed,  since  the  organic  lesions  (atrophic  patches  in  some  portions 
of  the  intestinal  tract  and  indefinite  degenerative  changes  in  the 
lungs,  liver  and  kidneys  found  postmortem)  are  not  uniform,  and 
rapidly  disappear  when  the  atrophic  infant  is  put  on  a  suitable  diet, 
which  may  vary  from  an  ideal  breast  milk  to  some  proprietary  arti- 
ficial food  (!).  In  this  group,  of  course,  are  not  included  cases  of 
marasmus  accompanying  tuberculosis,  syphilis  and  the  like. 

Whatever  the  pathology  and  cause,  the  symptomatology  is  very 
pathognomonic.  The  apparently  normally  born  infant,  after  thriving 
fairly  well  on  the  milk  mixture  it  has  been  receiving,  begins  to  show 
signs  of  ill  health  and  arrest  in  weight.  The  food  disagrees,  it  is 
occasionally  vomited  or  regurgitated.  The  stools  are  either  consti- 
pated, dry  and  soapy,  or  green  and  frequent,  scanty  in  quantity,  and 
contain  undigested  particles  of  food.  The  child  suffers  from  colic, 
especially  soon  after  feeding,  is  very  restless,  cries  and  whines  piti- 
fully, sleeps  poorly,  and  do  what  you  will,  emaciation  sets  in  and 
continues  at  a  rapid  pace.  Before  long  the  fontanelles,  the  eyes 
and  cheeks  are  sunken  (except  for  the  small  cushions  of  fat,  "sucking 
pads,"  over  the  buccinator  muscles)  ;  the  nose  and  chin  pointed;  the 
abdomen  is  at  first  prominent  but  later  retracted,  the  skin  wrinkled, 
often  hanging  in  folds,  and,  adding  to  this,  the  earthy  pallor  and 
senile  expression  of  the  face,  the  poor  creature  is  a  sight  dreadful  to 
behold.  Though  dried  up  to  mere  skin  and  bone,  with  respiration  shal- 
low and  pulse  bad,  the  infant  keeps  on  fighting  for  life  for  weeks  and 
months,  not  rarely  successfully.  On  the  other  hand,  sudden  death  may 
occur  when  least  expected. 

Unless  wrecked  by  intercurrent  diseases,  those  showing  tenacity 
to  life,  and  coming  under  observation  not  entirely  in  a  hopeless  state, 
stand   some    chance    to    regain   their    vitality    and    to    recover    com- 

501 


502^*^^     '  'WAhiitJ  DISEASES   OP   CHILDREN 

HTA^io:^ri:o  -0  5;:' -  j.jo  . 

,  ,,^  -ple.teily-.  The  prpgi;iosis  d,^ends  also  upon  the  duration  of  the  maras- 
mus, the  age  of  the  paiient — it  is  more  favorable  in  infants  over  four 
or  five  months  than  in  younger  ones — and  the  care  he  can  receive  from 
those  in  attendance.  The  concurrence  of  complications  or  sequelae, 
such  as  atelectasis,  edema,  pneumonia,  colicystitis,  pyelonephritis,  os- 
teitis, general  furunculosis-  and  the  like,  greatly  mar  the  chances  of 
recovery. 

Treatment. — As  athrepsia  almost  invariably  occurs  in  artificially 
fed  infants,  the  line  of  treatment  which  aj:  once  suggests  itself  is  to 
supplant  the  artificial  food  by  human  milk.  Indeed,  through  such 
a  change  miraculous  improvement  in  the  infant's  condition  may  often 


Fig.  142. — Marasmus  in  a  child  ten  months  old.     Note  "senile  face." 

be  observed  within  a  verj-  few  days,  requiring  no  further  treatment 
to  complete  prompt  and  uneventful  recovery.  Wet  nursing,  therefore, 
should  be  the  treatment  of  choice,  even  if  it  be  only  for  a  month  or 
two,  after  which  period  cow 's  milk  feeding  may  frequently  be  resumed 
with  success.  Athrepsia  in  breast-fed  babies  is  usually  due  to  an  ex- 
cess of  fat  or  some  other  constituent  in  the  milk.  In  such  cases 
the  difficulty  may  often  be  surmounted  by  allowing  the  baby  to  nurse 
only  from  five  to  ten  minutes  at  a  time,  and  giving  it  1  or  2  ounces  of 
plain  or  cereal  water,  or  diluted  lime  water,  before  and  after  each 
feeding,  or  a  light  skimmed  milk  mixture  after  nursing.    On  the  other 


DISTURBANCES   OP    METABOLISM  503 

hand  in  some  eases  there  is  a  deficiency  in  the  food  elements  and  the 
persistent  inanition  is  responsible  for  the  athrepsia.  When  the  serv- 
ices of  a  wet-nurse  are  not  obtainable  (for  financial  or  other  reasons), 
an  attempt  should  l)e  made  to  feed  the  baby  on  condensed  or  dry  milk 
in  low  dilution  with  plain  or  barley  water.  In  a  number  of  eases  fat- 
free  milk  (1:1  or  2:1),  in  small  quantities  to  begin  with,  proves  useful, 
and  to  bridge  over  the  critical  period  protein  milk  (1:1)  may  be  tried, 
occasionally  with  splendid  results.  Finally,  malt  soup  for  reasons 
rather  difficult  to  explain  (unless  it  be  assumed  that  the  marasmus  is 
the  result  of  acid  intoxication  which  is  arrested  by  the  carbonate  of 
potash  of  the  malt  soup)  will  often,  within  a  short  time,  convert  a 
baby  reduced  to  skin  and  bone  into  one  of  perfect  beauty. 

Lavage  and  colon  irrigation  are  useful  in  all  cases.  The  latter  should 
be  employed  daily ;  the  former  every  alternate  day,  or  more  often, 
if  the  return  water  contains  large  quantities  of  mucus,  and  the  vomit- 
ing persists.  In  the  latter  event  it  is  often  of  advantage  to  add  a 
little  boric  acid  or  bicarbonate  of  soda  to  the  sterile  water  used  for 
stomach  washing.  Of  medicinal  agents,  in  addition  to  an  occasional 
dose  of  calomel,  pancreatin  is  the  only  remedy  to  place  some  reliance 
upon.  One  or  two  grains  each  of  pancreatin  and  bicarbonate  of  soda 
may  be  administered  after  feeding. 

The  mouth  of  the  infant  should  be  kept  scrupulously  clean,  and 
the  buttocks  dry  and  clean,  to  prevent  stomatitis  and  intertrigo,  both 
of  which  form  frequent  complications.  The  child  should  not  be  left 
too  long  in  a  recumbent  posture,  lest  decubitus  or  passive  pulmonary 
congestion  supervene.  For  details  of  treatment  of  atelectasis,  edema, 
and  other  complications  the  reader  is  referred  to  the  respective  chap- 
ters on  the  subjects. 

Outdoor  life  and  plenty  of  fresh  air  Avhile  the  patient  is  indoors 
are  essential  to  successful  management  of  the  cases  in  question.  When- 
ever possible  the  child  should  summer  in  the  country.  Above  all, 
however,  breast  milk  is  the  specific  for  marasmus,  in  the  way  of  pro- 
phylaxis as  well  as  cure.     (See  ''Tuberculosis"  and  "Syphilis".) 

Rachitis 

(Rickets,  The  English  Disease) 

Rickets  is  one  of  the  most  common  affections  of  early  childhood. 
It  prevails  to  a  greater  or  less  extent  in  almost  all  parts  of  the  world, 
but  shows  a  predilection  for  poorly  born,  poorly  nourished  (also 
among  tlje  well  to  do)  and  poorly  housed  children  of  temperate  zones. 
The  immediate  cause  of  rickets  is  the  absence  or  deficiency  of  im- 


504 


DISEASES   OF    CHILDREN 


portant  elements*  in  the  food  or  failure  of  the  organism  to  assimilate 
the  same  in  sufficient  quantity,  J.  A.  Schabad  who  has  made  a  very 
exhaustive  study  of  the  subject  (Arch,  f.  Kinderheilk.,  Vol,  54,  Nos, 
1  to  3),  is  of  the  opinion  that  the  pivotal  point  in  the  morbid  mechanism 
of  this  disease  is  the  metabolism  of  phosphorus  and  not  of  calcium.  In 
the  evolution  of  rachitis  there  is  an  increased  elimination  of  both  of 
these  substances.  The  increased  excretion  of  phosphorus  is  greater  than 
can  be  accounted  for  by  the  amount  of  this  substance  and  the  equivalent 
amount  of  calcium  contained  in  the  bones,  so  that  it  is  probable  that  the 


Fig.   143. — Eachitic   "frons  quadrata"  in   an  infant  thirteen   months   old. 

nervous  tissues  share  in  the  pathologic  process.  The  increased  phos- 
phorus elimination  is  in  the  feces,  while  that  in  the  urine  is  really  less 
than  the  normal  (hypophosphaturia).  The  ratio  between  the  phosphorus 
content  of  the  urine  and  that  of  the  feces  is  changed.  The  normal  ratio 
in  nursing  infants,  80  -.20,  becomes  in  rickets  65  -.35,  while  in  artificially 
fed  infants  and  in  older  children  the  normal  ratio  of  60 :40  is  practically 
reversed  to  40:60.  In  the  convalescent  period  this  disturbed  ratio  of 
phosphorus  elimination  is  gradually  restored  to  normal,  while  the 
total  excretion  of  phosphorus  reaches  the  subnormal.  At  the  same 
time  there  is  a  relatively  great  increase  in  the  urinary  phosphorus,  the 


*Vitamines.      (See   p.    114.) 


DISTURBANCES   OP    METABOLISM 


505 


ratio  becoming  75:25.  There  is  a  close  relationship  between  the  cal- 
cium and  phosphorus  content  of  the  feces;  increase  in  the  intestinal 
elimination  of  calcium  goes  hand  in  hand  with  a  phosphorus  reten- 
tion and  vice  versa.  As  its  direct  and  most  conspicuous  result,  we 
have  a  great  diminution  of  the  inorganic  elements  of  the  bones  (barely 
35  per  cent,  whereas  in  normal  bone  they  amount  to  65  per  cent),  exag- 
gerated production  of  epiphj'seal  cartilage,  excessive  cell  proliferation 
beneath  the  periosteum,  and  incomplete  ossification  of  the  new  osseous 


Fig.  144. — Rachitie  beading  of  the  ribs,  "pot-belly,"  and  bow-legs. 

tissue.  The  same  process  takes  place  in  the  centers  of  ossification  of  the 
flat  bones.  This  is  especially  true  of  the  cranial  bones,  giving  rise  to 
areas  of  thickening  (bosses)  and  relative  thinning  (craniotabes).  As 
the  disease  advances,  chronic  inflammatory  changes  occur  also  in  the 
different  soft  structures  (muscles,  arteries,  etc.)  and  organs  (spleen, 
liver,  nervous  system,  etc.)  of  the  body,  leading  to  a  complex  pathologic 
entity  sui  generis — entirely  distinct  from  any  other  diseased  process. 
This  pathogenic  process  is  very  insidious  in  its  onset  and  its  course ; 
hence  in  the  beginning  rickets  is  very  apt  to  be  overlooked,  especially 
if  following  upon  some  other  illness. 


506 


DISEASES   OF    CHILDREN 


As  a  rule,  the  initial  symptoms  are  very  vague,  and  consist  of  re- 
current indigestion,  restlessness  and  debility :  a  nonpathognomonic 
group  of  symptoms,  rarely  arousing  the  anxiety  of  those  in  charge 
of  the  patient  so  as  to  seek  medical  advice.  When  seen  by  the  physi- 
cian, therefore,  the  disease  is  usually  in  full  bloom. 

The  skull  is  relatively  large,  the  forehead  broad  and  prominent 
in  profile  (frons  quadrata).  The  parietal  eminences  project  strongly, 
and  the  fontanelles,  especially  the  anterior  one,  and  the  sutures  fail 
to   close  in  due  time.     The   occiput  is  thinly  covered   with   hair   or 


Fig.  145. — High  degree  of  rachitic  spinal  curvature. 

entirely  bald,  and  here  and  there  yields  to  pressure  with  the  finger 
(craniotabes).  These  soft  spots  are  usually  quite  pronounced  when 
the  rachitis  sets  in  during  very  early  infancy. 

The  local  baldness  is  the  result  of  undue  pressure  and  friction  of 
the  occiput  against  the  pillow,  and  the  effect  of  profuse  perspiration 
which  is  most  marked  at  the  posterior  portion  of  the  head.  The  sweat- 
ing and  rubbing  of  the  head,  both  very  early  symptoms  of  rickets,  in  a 
way  are  correlated,  and  probably  due  to  cranial  hyperemia.  The 
rachitic  process  is  also  accompanied  by  more  or  less  severe  local 
pain  in  the  bones,  and  the  little  patients  will  often  cry  when  lifted 


DISTURBANCES    OF    METABOLISM 


507 


and  are  even  annoyed  by  the  pressure  of  ordinary  bed  covering  (hence 
kicking  off  of  the  blankets). 

The  lower  jaw,  instead  of  being  rounded,  becomes  flattened,  and 
its  alveolar  edge  is  turned  inward.  The  upper  jaw  is  also  more  or 
less  deformed,  and  the  teeth,  which  are  late  and  irregular  in  coming, 
are  asymmetrically  set,  conforming  with  the  altered  shape  of  the  jaws. 
Owing  to  the  deficiency  in  enamel  the  teeth  soon  turn  yellow,  brown- 
ish or  black,  are  streaked  and  brittle  and  subject  to  rapid  decay. 

The  rachitic  thorax  is  very  typical  in  appearance.  The  clavicles  are 
more  sharply  curved  than  in  the  normal,  and  occasionally  infracted ; 
the  costochondral  junctions  are  thickened,  bead-like  in  shape  (most 
marked  from  the  fourth  to  the  eighth  rib),  assuming  in  their  sloping 
course  from  above  downward  a  rosary-like  appearance  (rachitic  ros- 
ary) ;  the  sides  of  the  thorax  are  flattened  and  the  sternum  projects, 


Fig.   146. — Racliitic  bow-legs,  ^' jug  "-shaped  abdomen,  and  separation  of  epiphyses 

— ' '  double-jointed. ' ' 


as  in  birds,  hence  the  so-called  "pigeon"  or  "chicken"  breast    (pec- 
tus carinatum),  and,  finally,  the  lower  lateral  diameter  is  widened. 

The  vertebral  column,  although  rarely  affected  in  mild  forms  of 
rachitis,  invariably  suffers  in  severe  and  protracted  cases.  The  de- 
formities most  frequently  met  with  are  kyphosis  and  scoliosis.  The 
kyphosis  or  backward  curvature  usually  extends  from  the  middorsal 
to  the  sacral  region.  It  differs  from  tuberculous  kyphosis  by  being 
rounded,  end  in  the  early  stages  reducible  when  the  child  is  placed 
upon  the  abdomen  and  the  thighs  are  overextended.     (See  "Spondy- 


508  DISEASES   OF    CHILDREN 

litis,"  p.  462.)  Rachitic  lateral  curvature  or  scoliosis  is  produced  by 
the  relatively  heavy  Aveight  of  the  head  upon  the  yielding  (muscular 
and  ligamentous  insufficiency)  vertebral  column.  The  condition  is 
further  aggravated  by  allowing  the  patient  to  sit  up  or  walk  at  too 
early  an  age  and  for  too  long  periods,  and  by  the  habitual  unequal 
distribution  of  the  encunibrance.  As  regards  the  latter,  it  will  be 
noted  that  right-handed  persons  usually  carry  their  children  on  the 
left  arm,  so  as  to  have  the  right  hand  free,  and  in  consequence,  the 
right  pelvis  of  the  child  is  lifted  upward,  the  right  shoulder  tilted 
downward  and  the  middle  spine  shoved  laterally — lateral  scoliosis  with 
the  spinal  convexity  to  the  left.  While  rachitic  scoliosis  is  most  fre- 
quently observed  in  early  childhood,  rickets  undoubtedly  forms  also 
the  principal  cause  of  the  so-called  postural  scoliosis  of  school  chil- 
dren, the  curvature  being  merely  an  exaggeration  of  the  former  con- 
dition. Rachitic  scoliosis  (Fig.  145)  is  to  be  differentiated  from  congeni- 
tal scoliosis  (very  rare ;  as  a  rule  associated  with  other  congenital  deform- 
ities) ;  cicatricial  scoliosis  (following  operation  for  purulent  pleurisy)  ; 
paralytic  scoliosis,  in  association  with  poliomyelitis,  etc.  (Fig.  189); 
spondylitic  scoliosis,  usually  kyphoscoliosis  (see  "Spondylitis,"  p. 
462)  ;  and  static  scoliosis  (in  congenital  or  acquired  shortening  of  one 
lower  extremity).  Although,  as  previously  alluded  to,  rachitic  scoliosis 
is  reducible  in  its  early  stage,  if  let  alone  for  a  long  period,  the  deform- 
ity is  apt  to  remain  permanent,  notwithstanding  the  disappearance 
of  the  other  symptoms  of  rachitis. 

The  extremities  very  rarely  escape  involvement.  In  the  upper  ex- 
tremities we  usually  find  marked  enlargement  of  the  epiphyses  at  the 
wrists,  and  less  frequently  at  the  elbow.  In  creeping  infants  the 
radius  and  ulna  are  often  curved  and  sometimes  infracted,  and  in 
severe  cases  the  hand  is  separated  as  it  were  by  a  furrow — "double 
jointed."  Occasionally  there  is  also  an  enlargement  of  the  ends  of  the 
metacarpal  bones  or  the  phalanges. 

By  far  more  marked  are  the  deformities  of  the  lower  extremities. 
The  soft  tibia  and  fibula  are  ill  prepared  to  balance  the  weight  of  the 
body.  The  flimsy  fundament  thus  tumbles  under  its  encumbrance. 
The  hapless  patient  learns  to  walk  late  and  with  difficulty,  or,  as  it 
were,  "forgets"  or  unlearns  how  to  walk,  or  refuses  even  to  stand  be- 
cause of  pain  in  the  legs.  If  he  continues  to  walk,  the  tibiae  and  fibulae 
bend  either  outward  (bowlegs — genu  varum;  0-shaped)  inward  (knock- 
knees — genu  valgum;  X-shaped)  forward  (saber-blade  shaped)  or,  in 
severe  cases,  simultaneously  in  different  directions.  Similarly  to  what 
occurs  in  the  upper  extremities,  there  is  also  an  enlargement  of  the 
epiphyseal  ends  of  the  bones,  and  occasionally  infraction  of  the  diaphy- 
ses.    Children  sitting  crossed-legged  may  present  also  more  or  less  pro- 


DISTURBANCES   OF    METABOLISM 


509 


nounced  curvatures  of  the  femur  and  pelvis.     Kachitic  flatfoot  is  rare. 

The  course  of  these  deformities  varies.  In  the  majority  of  mild  and 
moderately  severe  cases  spontaneous  recovery  occurs  with  improvement 
of  the  general  condition.  On  the  other  hand,  in  extreme  cases,  where,  as 
a  rule,  growth  is  greatly  retarded,  the  curvatures  persist  and  require 
forcible  corrective  measures,  or  surgical  interference. 

The  muscles  generally  participate  in  the  rachitic  process.  They  are 
thin  and  flabby  and  partly  responsible  for  the  difficulty  in  sitting  and 
walking  ("pseudoparalysis")  ;  abdominal  distention  ("potbelly")  ;  and 


Fig.  147. — Eachitic  knock-knee  in  girl  six  years  old. 

for  the  constipation  and  prolapsus  recti.  The  muscular  insufficiency  may 
be  associated  with  overfatness,  and  mask  the  local  rachitic  mani- 
festation. 

The  ligaments  are  more  or  less  lax  allowing  undue  mobility  at  the 
larger  joints,  and  giving  rise  to  the  abnormality  known  as  "double 
joints." 

Coincidently  with  and  in  a  measure  because  of  the  gross  alterations 
in  the  body  framework,  manifold  changes  occur  also  in  the  functions 
and  structures  of  other  organs  of  the  body. 

The  respiratory  system  suffers  early.  The  contracted  chest  com- 
presses its  contents  and  disturbs  the  equilibrium  of  the  thoracic  and 
abdominal  organs.  The  area  of  breathing  space  is  reduced,  hence, 
respiration  is  more  or  less  interfered  with,  and  the  tendency  to  respi- 
ratory disease  greatly  increased.     The  latter  is  favored  also  by  the 


510  DISEASES   OF    CHILDREN        * 

timidity  of  the  parents  to  expose  their  delicate  babies  to  outdoor  air, 
keeping  them  huddled  up  in  poorly  ventilated  rooms  and  thus  reducing 
their  power  of  resistance  to  infection.  In  consequence  of  this,  slight 
catarrhal  affections  of  the  nasopharynx  or  larynx,  instead  of,  as  in 
the  normal,  yielding  promptly  to  suitable  treatment,  they  persist  indefi- 
nitely and  lead  to  capillary  bronchitis  or  bronchopneumonia,  not  rarely 
with  fatal  issue  or  greatly  protracted  convalescence  with  a  predisposi- 
tion to  tuberculous  infection.  As  an  immediate  result  we  have  also  pro- 
found secondary  anemia — reduction  of  hemoglobin  and  red  blood  cells 
and  moderate  leueocytosis.  ■  The  child  is  pale,  sometimes  waxy  in  color; 
its  digestion  is  poor;  diarrhea  alternates  with  constipation  (often  the 
feces  are  hard  and  the  rectum  is  unable  to  expel  the  lump  until 
aided  by  mechanical  means),  the  latter,  however,  preponderating.  The 
liver  and  spleen  are  more  or  less  enlarged  and  help  to  distend  the  ab- 
domen, sometimes  to  such  an  extent  as  to  greatly  resemble  tuberculous 
peritonitis  (see  p.  155).  R.achitic  children  are  very  irritable,  sleep  rest- 
lessly, and  show  a  great  disposition  toward  different  spasmodic  condi- 
tions. Spasmus  glottidis,  spasmus  nutans,  eclampsia  and  tetany  are 
frequent  complications  of  severe  and  protracted  cases  of  rickets,  es- 
pecially in  very  young  infants. 

Cases  of  rickets  presenting  the  local  and  general  symptoms  here  de- 
picted usually  offer  no  diagnostic  difficulties.  Less  typical  cases,  how- 
ever, may  be  confounded  with  cretinism,  achondroplasia,  congenital 
syphilis,  incipient  hydrocephalus,  and  osteogenesis  imperfecta — a  group 
of  diseases  which  not  only  have  several  symptoms  in  common  and  are 
to  a  certain  extent  etiologically  correlated,  but  may  also  be  associated 
with  rickets. 

In  cretinism  there  is  marked  mental  deficiency ;  the  tongue  thick  and 
protruding  from  the  mouth ;  as  the  child  grows  older  there  is  very  pro- 
nounced disparity  between  its  age  and  body  length. 

Achondroplasia  is  characterized  by  a  striking  disproportion  between 
the  length  of  the  trunk  and  extremities ;  the  curvature  of  the  shafts 
of  the  bones  is  due  to  embryonic  defective  development  and  not,  as  in 
rickets,  to  softness  of  the  bones;  the  fingers  do  not  lie  parallel  as  in  the 
normal,  but  are  spread  out  like  ribs  of  an  open  fan. 

The  epiphyseal  thickening  at  the  ribs  and  the  long  bones  of  syphilis 
hereditaria,  as  a  rule  is  observed  soon  after  birth  in  association  with 
other  symptoms  of  syphilis  which  yield  promptly  to  specific  treatment. 

Incipient  hydrocephalus  has  several  symptoms  in  common  with 
rickets  (separation  of  the  fontanelles,  softening  of  the  cranial  bones, 
irritability  of  the  nerve  system).  In  hydrocephalus,  however,  the 
cranial  distention  is  rapidly  progressive  in  character,  leaving  the  long 
bones  of  the  body,  which  suffer  most  in  rickets,  almost  unmolested. 


DISTURBANCES   OP    METABOLISM  511 

Osteogenesis  imperfecta  differs  from  rickets  in  that  in  the  former 
the  bones  are  so  soft  that  they  can  be  cut  and  bent,  splintered  and 
fractured  in  several  places. 

The  importance  of  an  early  diagnosis  cannot  be  too  strongly  em- 
phasized, since  upon  it  depends  the  prognosis  and  the  success  of  the 
treatment.  While  it  is  generally  admitted  that  rachitis  per  se  is  not 
dangerous  to  life,  and  that  in  a  number  of  cases  spontaneous  recovery 
is  possible,  the  indiiTerenee  of  the  laity  as  well  as  the  physician  re- 
garding early  and  persistent  treatment  is  stronglj'  to  be  deprecated. 
Spontaneous  recovery  is  rarely  complete.  On  the  contrary,  without 
suitable  treatment,  the  majority  of  children  are  left  stunted  in  growth, 
distorted  in  shape  and  features,  and  depressed  in  spirit — in  short, 
poorly  qualified  to  struggle  for  an  existence  and  to  compete  with  the 
fellowmen  favored  by  good  fortune  with  sound  mind  and  body. 

Treatment. — Rickets  is  preventable  by  abundance  of  sunlight  and 
fresh  air  and  by  a  mixed,  nutritious  diet.  In  the  absence  of  contra- 
indications, children  over  three  months  of  age  should  receive  in  addi- 
tion to  milk,  small  quantities  of  carbohydrates  and  orange  juice;  those 
over  six  months,  also  thin  meat  and  vegetable  soups;  those  over  nine 
months,  half  of  or  a  whole  soft-boiled  egg,  some  beef  juice,  and  a 
little  toasted  bread  with  sweet  butter;  and  those  over  a  year,  one 
egg  daily,  some  thick  fresh  vegetable  soup,  with  finely  scraped  beef  or 
chicken,  oatmeal  gruel,  light  cocoa,  etc.,  and  occasionally  a  small 
quantity  of  finely  scraped  fresh  beef  spread  on  bread  or  mixed  with 
baked  potato.  Season  permitting,  raw  milk  should  be  given  in  pref- 
erence to  boiled,  sterilized  or  pasteurized. 

Eachitic  deformities  may  be  prevented  by  avoiding  superencum- 
brance  of  the  spine  and  extremities.  Infants  with  incipient  rickets 
should,  as  much  as  possible,  be  kept  off  their  feet,  and  advantageously 
held  in  the  recumbent  posture,  allowing  them  to  remain  in  the  upright 
position  only  for  short  periods  at  a  time. 

The  suggestions  just  made  apply  as  well  to  the  management  of  fur- 
ther advanced  cases  of  rickets.  Here,  too,  sunshine  and  nitrogenous 
diet  in  abundance  and  removal  of  the  superincumbent  weight  of  the 
body  are  the  remedies  par  excellence.  To  these  we  should  add  hydro- 
therapy (sea  salt  baths),  massage  and  passive  motion,  and  corrective 
light  braces  where  the  deformities  persist.  Operative  corrective  pro- 
cedures should  be  reserved  for  deformities  of  over  three  years'  stand- 
ing, since  slight  curvatures  usually  respond  to  nonoperative  antirachi- 
tic measures. 

As  auxiliaries,  especially  with  the  view  of  overcoming  the  anemia 
and  the  deficiency  of  mineral  elements,  the  syrupus  calcii  et  sodii 
hypophosphitum  (N.  F.),  the  syrupus  hypophosphitum  compositus  (U. 


)12 


DISEASES   OP   CHILDREN 


S.  P.),  the  syrupus  ferri  iodidi  and  the  liquor  phosphori  (N.  F.)  are  of 
great  therapeutic  vahie.  However,  cod  liver  oil  is  the  specific  in  rachitis 
and  may  advantageously  be  combined  with  the  aforementioned  remedies. 
(See  p.  451.) 

In  intractable  cases  organotherapy,  especially  the  extracts  of  thy- 
roid, thymus,  and  pituitary  glands  and  red  bone  marrow  should  be 
given  a  fair  trial.  A  sojourn  at  the  seashore  is  highly  to  be  recom- 
mended. Cases  of  florid  rachitis  of  older  children  up  to  ten  years  of 
age  are  on  record.    They  are  usually  spoken  of  as  rachitis  tarda. 

Achondroplasia* 

(Chondrodystrophia  Fetalis,  Fetal  Rickets,  Micromelia) 

These  terms  are  used  to  designate  a  peculiar  type  of  congenital 
dwarfism  arising  from  early  fetal  arrest  of  growth  of  the  bones  that 


Fig.   148. — Achondroplasia  in  ten-month-old  baby.     Note   great   length   of   trunk  as 
compared  with  the  short  extremities. 

•Though    not    an    acquired    disease,    this    subject    is    treated    here    in    order    to    emphasize    its 
many  differences  from  rickets. 


DISTl^RnAXCKS    OF    METABOI>ISM 


5]  3 


are  formed  in  cartilajje,  leavinp:  the  ])ones  tliat  are  laid  down  in  nieni- 
l)rane  unaffected.  Thus,  we  have  shortenin^r  of  the  extremities,  aiul  of 
the  bones  of  the  base  of  the  skull,  while  the  bones  of  the  vault  of 
the  cranium  and  the  trunk  are  normal.  This  peculiar  chondral  dys- 
trophy produces  the   following  characteristic   statural   disparities : 


Fig.  1-49. — Aclioiulroplasia  (left).  Botli  children  are  of  the  same  age.  Note  the 
short  legs  and  long  trunk  in  the  aehondroplasiac  as  compared  Avith  the  normal 
(right)  child.     (After  Drs.  Wood  and  Hewlett.) 


Shortness  of  the  extremities  as  compared  with  the  normal  (relativeh' 
long)  abdomen ;  the  forearms  are  longer  than  the  arms  and  the  legs  longer 
than  the  thighs ;  bowing  of  the  extremities,  especially  loAver,  and 
thickening  of  the  terminal  epiphyses;  limited  power  of  extension  of 
the  upper  extremities;  peculiar  fan-like  divergence  of  the  thick,  uni- 


514  DISEASES   OP   CHILDREN 

formly  sized  fingers,  the  so-called  "trident  hand";  marked  narrowing 
of  the  pelvis;  lordosis;  protuberant  abdomen;  narroAving  of  the  base 
of  the  skull  ("pug-nose,"  broadening  of  the  jaws)  as  compared  with 
the  normal  (relatively  large)  upper  part  of  the  skull.  The  skin  and 
nails  are  normal ;  the  hair  is  soft  and  abundant  in  growth.  Intellect  is 
usually  fairly  normal.  The  great  majority  of  eases  of  achondroplasia 
die  in  utero  or  soon  after  birth.  Those  who  survive  may  attain  old 
age.     They  very  rarely  exceed  4  feet  in  height. 

Scorbutus  Infantum 

(Moeller-Barlow's  Disease,  Scurvy,  Acute  Rickets) 
Infantile  scurvy  is  an  acute  specific  hemorrhagic  affection  of  as  yet 
unknown  origin.  It  is  probably  due  to  direct  microbic  infection  or 
toxemia  resulting  from  intestinal  putrefaction.  As  the  disease  oc- 
curs principally  in  infants  from  six  to  eighteen  months  old,  the 
period  when  nutritional  disturbances  are  most  rampant,  there  is  every 
reason  to  believe  that  malnutrition  is  the  most  active  predisposing 
cause.  This  explains  also  the  frequency  with  which  infantile  scurvy 
is  observed  in  infants  fed  exclusively  on  boiled  or  sterilized  milk 
(milk  deprived  of  some  of  its  nutritious  qualities),  or  poor  breast 
milk,  in  short,  on  food  lacking  some  essential  elements  (vitamines*). 
I  had  the  opportunity  to  observe  scurvy  in  a  pair  of  twins  six  and 
a  half  months  old,  who  were  partly  breast  fed.  The  disease  developed 
in  both  of  them  almost  at  the  same  time,  and  subsided  promptly  on  the 
administration  of  small  quantities  of  lemon  juice,  mixed  vegetable 
soups  and  raw  milk  in  addition  to  the  breast  feeding.  The  simultan- 
eous occurrence  of  the  affection  in  both  babies  and  the  absence  of  a 
history  of  faulty  feeding  tend  to  the  infectious  theory  of  the  causation 
of  scurvy.  The  principal  pathologic  changes  in  scurvy  consist  of  an 
increase  in  the  width  and  vascularization  of  the  cartilage  zone  and 
hemorrhage  into  the  loose  vascular  layer  of  the  connective  tissue  of  the 
periosteum  adjacent  to  the  bone,  thus  leading  to  detachment  of  the 
periosteum  from  the  bone  and  forming  a  thick  sheath  of  blood  clot 
underneath  it.  The  lower  and  upper  extremities  and  the  ribs  are  most 
frequently  affected.  Hemorrhages  take  place  also  in  the  mucous 
membranes  of  the  hard  palate  and  gums,  in  the  muscles  and  more 
rarely  in  the  serous  cavities  and  solid  viscera.  There  is  anemia  but  no 
leucocytosis.  The  calcium  content  of  the  blood  is  decidedly  diminished 
(Hess). 

The  onset  of  the  disease  is  usually  sudden  or,  less  frequently,  pre- 
ceded by  malaise  or  digestive  disturbance  of  a  few  days'  duration 

*See   p.    114. 


DISTURBANCES   OF    METABOLISM 


515 


and  slight  fever.  The  child  is  restless,  cries  when  it  tries  to  move 
itself  or  when  it  is  being  handled.  This  symptom  is  the  result  of 
pain  and  tenderness  especially  in  the  lower  extremities.  For  fear 
of  pain  the  patient  instinctively  ceases  to  move  its  limbs  (pseiidoparal}-- 
sis).  Examination  of  the  extremities  soon  reveals  at  the  diaphyses  of 
one  or  both  femurs,  more  rarely  of  the  tibia  and  fibula,  or  upper 
limbs,  spindle-shaped,  colorless,  smooth,  nonfluctuating  swellings  sur- 
rounding the  bones.  The  tumefactions  for  the  most  part  are  due  to 
subperiosteal  hemorrhage.     Exceptionally  there  is  bleeding  also  from 


Fig.  150. — Scorbutus  in  a  fiftoen-niontlis-old  infant.     Note  hemorrhage  from  the  gums 
and  in  the  skin,  and  swelling  of  lower  extremities. 


beneath  the  periosteum  of  the  ribs  and  of  the  bones  of  the  head  (pro- 
trusion of  the  eyeball  in  subperiosteal  hemorrhage  of  the  frontal  bone) 
and  face,  and  occasionally  spontaneous  separation  of  the  epiphysis 
from  the  shaft  of  the  bone,  leading  to  bone  infraction,  impaction  or 
fracture.  'The  next  important  symptom  of  infantile  scurvy  is  spongi- 
ness   and   discoloration    (minute   transient   ecchymoses)    of   the   gums. 


516  DISEASES   OP    CIIir.DREN 

with  a  tendency  to  bleed.  In  (|uite  a  niimhor  of  cases  the  hemor- 
rhagic tendency  extends  also  to  the  skin,  subcutaneous  tissue  (typical 
"black  eye"  after  a  fit  of  crying  or  ^lugliing,  also  discoloration  and 
proptosis  of  an  eye  resembling  that  of  chloroma),  to  the  mucous  mem- 
branes and  the  viscera  (dysentery!),  so  that  as  a  result  of  loss  of 
blood  profound  anemia,  edema  and  albuminuria  supervene.  On  the 
other  hand,  some  cases  pursue  a  very  mild  course  {formes  frustes),  es- 
pecially if  recognized  early  and  treated  energetically.  Except  occa- 
sional permanent  hyperostosis  of  the  affected  shafts  of  the  extremities, 
the  prognosis  as  a  whole  is  favorable,  recovery  usually  taking  place 
within  from  a  few  weeks  to  as  many  months.  Neglected  cases,  how- 
ever, may  end  fatally  from  the  aforementioned  complications,  or  from 
pneumonia. 

Treatment. — An  antiscorbutic  diet  and  fresh  air  form  the  treatment 
par  excellence.  Prompt  improvement  and  rapid  recovery  usually  fol- 
low the  administration  of  fresh  cow's  milk,  fresh  fruit  juice  (lemon, 
orange,  or  pineapple),  fresh  vegetable  soups,  beef  juice,  and  in  older 
children  fresh  eggs  and  vegetables  (potato  puree,  carrots,  tomatoes, 
fresh  or  canned — Hess — spinach,  etc.).  Where  convalescence  is  pro- 
tracted we  may  prescribe  the  compound  syrup  of  hypophosphites 
(U.S.P.)  with  extract  of  malt  and  cod  liver  oil. 

Infantile  scurvy  may  be  mistaken  for  rheumatism,  peliosis  rheu- 
matica,  purpura  hemorrhagica,  syphilitic  epiphysitis,  osteomyelitis, 
rickets,  and  occasionally  (when  the  orbit  is  involved)  for  chloroma. 

In  rheumatism  the  swelling  is  usually  localized  at  the  articulations 
and  "jumps"  from  one  place  to  another.  It  is  accompanied  b}^  fever 
and  responds  to  the  salicjdates.    Hemorrhages  are  absent. 

Peliosis  rhewmatica  is  characterized  by  deep  red  or  bluish  spots,  as 
a  rule,  limited  to  the  extremities.     It  usually  occurs  in  older  children. 

Purpura  hemorrhagica  is  free  from  diaphyseal  hematomas  and  pain. 

Syphilitic  ■epiphysitis  is  free  from  the  hemorrhagic  tendency,  and 
often  presents  other  syphilitic  lesions. 

Osteomyelitis  is  associated  with  high  fever  and  rapid  local  suppura- 
tion. 

Rickets  is  free  from  acute  pain  and  hemorrhagic  symptoms,  but 
has  other  pathognomonic  symptoms.  It  responds  very  slowly  to  treat- 
ment. It  is  worth  remembering,  however,  that  rickets  and  scurvy 
may  coexist. 

Chloroma  or  green  tumor  usually  shows  a  predilection  for  the  skull 
(temporal  fossae  and  orbits),  giving  the  child  a  characteristic  frog-like 


DISTURBANCES    OF    METABOLISM  517 

appearance.     It  is  a  grave  blood  disease — profound  anemia  with  rel- 
ative and  absolute  increase  in  lymphocytes. 

Beriberi 

(Kakke.    Polyneuritis  Endemica) 

There  is  still  considerable  diversity  of  opinion  regarding  the  etiology 
of  beriberi.  While  the  majority  of  observers  attribute  the  disease  to 
a  polished-rice-diet,  to  an  insufficiency  in  vitamines,t  some  clinicians 
believe  it  to  be  due  to  an  unknown  infectious  agent.  Beriberi  prevails 
extensively  in  Japan,  China,  Indo-China,  Borneo,  Philippine  Islands, 
Straits  Settlements,  Malay  States,  Java  and  Sumatra,  Brazil  and  Ice- 
land.. 

It  ordinarily  runs  an  afebrile  course,  developing  insidiously  with 
epigastric  pain,  debility,  sensation  of  precordial  oppression  and  other 
symptoms  of  dilatation  of  the  heart.  Physical  examination  elicits, 
weakness  of  the  extremities,  hobbling  gait  with  the  legs  widelj^  apart : 
immobility  to  stand  with  the  eyes  shut,  wasting  of  the  anterior 
tibial  and  peroneal  muscles,  loss  of  knee  jerks,  preceded  by  exaggera- 
tion; later  also  wrist  drop,  and  edema,  especially  of  the  lower  ex- 
tremities, in  the  absence  of  other  signs  of  nephritis.  Sometimes  the 
disease  runs  an  acute  course  with  paralysis  spreading  tp  the  respira- 
tory muscles,  when  it  usually  proves  fatal.  Otherwise  the  mortality 
ranges  between  from  5  to  50  per  cent,  all  depending  upon  how  early 
the  treatment  is  initiated. 

Treatment. — Rest  in  bed,  nutritious  diet  (fresh  milk,  fresh  fruit  and 
and  vegetables,  meat  broths  and  juice,  unpolished  rice  and  other  ce- 
reals), autolyzed  yeast*  (5  to  30  drops  t.  i.  d.),  tonics,  such  as  iron, 
quinine  and  strychnine  and  sometimes  digitalis  in  cases  of  heart  weak- 
ness. 

Pellagra 

This  disease  is  not  rarely  met  with  in  this  country,  especially  in 
the  south.  Its  cause  is  still  the  subject  of  considerable  controversy. 
Some  clinicians^  attribute  it  to  a  vegetarian  diet,t  with  a  preponderance 
of  cereals,  others^  maintain  that  it  is  an  insect-borne  infection,  since 
it  prevails  during  the  summer  and  early  autumn,  when  certain  gnats 
of  the  genus  Simulium  abound.    It  may  readily  be  assumed  that  while 


tSee  page   114. 

*Dry  pressed  brewer's  yeast  is  placed  in  an  incubator  at  a  temperature  of  37.5°  C.  for  32 
hours;  the  liquid  is  allowed  to  gravitate  through  a  paper  filter  and  then  kept  at  room  temperature 
for  another  10  hours  until  the  purin  bodies  have  separated  when  it  is  again  filtered.  The  auto- 
lyzed yeast  if  iept  on  ice  will  not  spoil  for  quite  a  long  time.     It  is  not  to  be  used  if  mould  forms. 

^Goldberger,    )\^heeler   and    Lydenstricker    (Jour.   A.    M.   A.,    September   21,    1918). 

-Jobbling  and  Petersen   (Jour.  Infect.  Dis.,   \'ol.  18). 


518  DISEASES   OF    CHILDREN 

an  infection  is  the  exciting  cause  of  tlie  disease,  a  deficiency  of  fresh 
green  vegetables  and  animal  protein  in  the  dietary  serves  as  the  most  im- 
portant predisposing  cause. 

Pellagra  is  characterized  by  symmetrical  erythema  or  dermatitis, 
chiefly  on  the  exposed  surfaces  (neck,  face  and  extremities),  red,  fis- 
sured tongue,  diarrhea  or  constipation,  restlessness,  insomnia,  pares- 
thesia, and  disturbance  of  the  knee  jerks  (either  exaggerated  or  ab- 
sent). 

It  is  readily  curable  by  change  of  climate,  restriction  of  cereals,  and 
feeding  on  animal  proteins,  such  as  fresh  milk,  beef  juice,  broths,  eggs, 
meats,  etc.,  also  fresh  fruits.  Hematic  tonics.  The  skin  should  be  pro- 
tected from  the  rays  of  the  sun,  and  the  eruptions  treated  with  calamine 
lotion  and  similar  mild  remedies. 

Diabetes  Mellitus 

(Glycosuria) 

Within  recent  years,  with  increased  interest  in  accurate  diagnosis, 
the  number  of  cases  of  diabetes  in  children  recorded  has  greatly  in- 
creased. In  former  years  undoubtedly  many  of  the  rapidly  fatal 
cases  escaped  observation.  The  importance  of  careful  examination 
of  the  urine  of  older  children  and  infants  suffering  from  polyuria  or 
enuresis,  therefore,  cannot  too  strongly  be  emphasized. 

We  distinguish  two  forms  of  glycosuria :  glycosuria  spuria  (tem- 
porary or  dietetic),  and  glycosuria  vera  (diabetes  mellitus).  The 
first  variety  is  comparatively  of  little  clinical  importance.  It  is  the 
result  of  consumption  of  sugar  greater  in  quantity  than  can  be  assim- 
ilated, and  usually  disappears  after  arrest  of  the  causal  factor. 

On  the  other  hand,  diahetes  mellitus  is  an  extremely  fatal  affection, 
death  taking  place,  in  violent  cases,  sometimes  after  a  few  weeks  or 
months,  or  in  less  acute  cases,  often  within  a  year  or  two  at  the  latest. 
This  variety  is  often  hereditary. 

The  onset  of  diabetes  mellitus  is  rather  sudden.  The  child  begins 
rapidly  to  lose  in  weight,  notwithstanding  good  appetite,  suffers  from 
excessive  thirst,  passes  a  large  quantity  (75  to  115  ounces)  of  urine 
(often  enuresis  nocturna  as  well  as  diurna!),  of  high  specific  gravity 
(1,030),  containing  a  large  proportion  of  sugar,  at  times  acetone  and 
diacetic  acid,  and  loses  in  vitality  from  day  to  day.  In  addition  to  these 
symptoms  there  are  also  digestive  disturbances,  dryness  of  the  skin,  skin 
affections  (furunculosis,  lichen-like  eruption  with  severe  itching)  onychi- 
tis, cataract,  nerve  disorders  (e.  g.,  Friedreich's  ataxia),  obstinate  acetone 
odor  from  the  mouth,' etc.    The  course  of  the  disease  varies.    As  a  rule,  it 


DISTURBANCES   OF    METABOLISM 


519 


is  more  rapid  than  in  adults ;  the  younger  the  patient  the  more  violent  the 
course.  Death  usually  occurs  as  a  result  of  general  exhaustion  or  in- 
tercurrent diseases,  such  as  pneumonia,  tuberculosis,  and  the  like, 
and  is  frequently  preceded  by  coma  diabeticum  or  uremia.  Kecov- 
eries,  however,  are  also  on  record. 

Treatment. — Every  effort  should  be  made  to  trace  the  cause  of  the 
disease  and  to  combat  it  energetically.  As  congenital  or  acquired 
syphilis  has  frequently  been  found  to  play  an  essential  part  in  the 
causation  of  diabetes,  it  is  prudent  to  subject  the  patient  to  a 
course  of  antisyphilitic  treatment.  We  have  no  means  at  our  com- 
mand to  influence  the  other  supposed  etiologic  factors  of  diabetes, 
such  as  traumatism  to  the  head,  shock,  tuberculosis,  various  infec- 
tious diseases,  etc.  The  time  is  not  distant,  however,  when  the  true 
nature  of  the  affection  will  be  disclosed,  and  the  remedies  found  which 
will  greatly  aid  us  in  the  prevention  and  arrest  of  the  disease  at 
its  very  inception.  Until  this  blissful  moment  arrives  we  will  have 
to  continue  groping  in  the  dark,  empirically  treat  symptoms,  and  de- 
pend chiefly  upon  a  restricted  diet,  which  at  best  never  strikes  the 
root  of  the  evil,  and  is  hardly  practicable  in  diabetes  of  early  child- 
hood. Wherever  possible  (especially  in  older  children),  the  diet  should 
consist  of  fresh  meat  soups  and  broths;  bread  and  biscuits  of  gluten 
flour,  with  cream  and  butter ;  eggs ;  moderate  quantities  of  meats  of  all 


FOODS  AREANGED  ACCORDING  TO  THEIR  APPROXIMATE  PERCENTAGE 
OF  CARBOHYDRATES  (DR.  HALPERN) 


(1)  5% 

Presh  Vegetables: 

Lettuce        Tomatoes 
Spinach         Rhubarb 
Sauerkraut        Leeks 
String  beans 
Celery        Egg  plant 
Asparagus    Cabbage 
Cucumbers    Radishes 
Brussels  sprouts 
Sorrel      Beet  greens 
Endive    Water  cress 
Dandelion  greens 
Swiss  chard 

Pumpkin 
Sea  kale  Kohl-rabi 
Broecali  ^ 

Vegetable  marrow 
Cauliflower 

Canned  Vegetables: 

Asparagus 
Spinach        ' 
String  beans 


Fruits: 
Ripe  olives 
Grape  fruit 

Nuts: 
Butternuts 
Pignolias 

Miscellaneous: 
Unsweetened  &  un- 
spiced  pickles, — 
clams,  fish,  oy- 
sters, scallops,  liv- 
er,  roe. 

(2)    lOo/o 
Fresh  Vegetables: 
Onions  Carrots 

Squash  Okra 

Turnips  Beets 

Mushrooms 

Fruits: 
Lemons 
Oranges 
Cranberries 
Strawberries 
Blackberries 


Gooseberries 
Peaches 
Pineapple 
Watermelon 

Nuts: 
Brazil 

Black  walnuts 
Hickory 
Pecan 
Filbert 

(3)    15o^ 
Fresh  Vegetables: 

Green  peas 

Artichokes 

Parsnips 

Canned  Vegetables: 

Lima  beans 

Fruits: 
Apples 
Pears 
Apricots 
Cherries 
Blueberries 


Currants 

Raspberries 

Huckleberries 

Nuts: 

Almonds 
English  walnuts 
Beechnuts 
Pistachio 
Pine 

(4)  20% 

Fresh  Vegetables: 

Potatoes 
Shell  beans 
Baked  beans 
Green  corn 
Boiled  rice 
Boiled  macaroni 

Fruits: 

Plums  Bananas 

Nuts: 
Peanuts 

(5)  40% 

Chestnuts 


520  DISEASES    OF    CHILDREN 

kinds,  and  fish,  oysters  and  scallops;  well  boiled  spinach,  asparagus, 
string  beans,  cauliflower,  cabbage,  radishes,  and  turnips;  protein  milk; 
fresh  sour  fruit,  such  as  grapefruit,  lemon,  occasionally  cranberries  and 
blackberries.  Saccharin  instead  of  sugar.  In  infants  milk  and  amylacea 
are  indispensable,  but  should  be  restricted  as  much  as  possible.  Oatmeal 
gruel  seems  to  work  well  in  some  cases.  Mild  hydrotlierapeutic  pro- 
cedures, and  light  exercise  are  useful.  Bicarbonate  of  soda  in  large 
doses  should  be  administered  to  prevent  acidosis.  Opium,  in  some 
form,  and  arsenic,  in  addition  to  cod  liver  oil  and  iron,  are  the  only 
drugs  of  therapeutic  value.  Complications  should  be  treated  accord- 
ing to  indications.  Koplik  is  of  the  opinion  that  the  Allen  treat- 
ment of  fasting,  as  employed  in  adults,  is  also  applicable  in  children. 
During  the  treatment  the  child  should  be  kept  in  bed. 

Diabetes  Insipidus 

(Polyuria) 

Polyuria,  like  glycosuria,  may  be  transient  or  persistent.  Transient 
polyuria  is  quite  common  in  children  and  is  usually  of  nervous  origin. 
On  the  other  hand,  persistent  polyuria — diabetes  insipidus — is  compar- 
atively rare.  It  is  manifested  by  excessive  thirst,  polyuria  (pale, 
sugar-free  urine  of  low  speciiic  gravity,  not  exceeding  1,006),  dry 
skin,  disturbances  of  the  digestive  and  nervous  systems.  The  course 
is  A^ery  protracted,  but  the  prognosis  quoad  vitam  favorable.  Perma- 
nent recovery  is  rare. 

As  the  etiology  is  obscure  (disease  of  the  hypophysis  cerebri?),  little 
can  be  expected  from  treatment  except  in  cases  due  to  syphilis  which 
frequently  yield  to  antisyphilitic  medication.  Change  of  air,  hydro- 
therapy, a  nitrogenous  diet  and  an  ample  supply  of  water  act  bene- 
ficially. 

A  number  of  clinicians  have  lately  been  recommending  pituitary 
solution  (posterior  lobe)  in  doses  of  from  0.25  to  1  e.c.  subcutaneously 
and  also  by  mouth.  The  output  of  urine  is  reduced,  but  only  tem- 
porarily. 

Adipositas  . 

(Lipomatosis  Universalis,  Obesity) 

Contrary  to  what  is  observed  in  older  children  or  adults,  overfatness 
in  infants  very  rarely  gives  rise  to  constitutional  disturbances.  As  a 
rule,  the  fatness  subsides  when  the  child  begins  to  walk  about. 

In  older  children  obesity  is  often  associated  with  marked  anemia, 
shortness  of  breath  and  fatty  degeneration  of  the  heart.    If  such  symp- 


DISTrRBAXCES   OF    METABOLISM 


521 


Fig.   151. — Adipositas;    child   weighs  thirty-six  pounds  at  .eight  montlis. 

toms  appear,  it  is  essential  to  eliminate  fats  and  carbohrdrates  from  the 
dietary  and  to  recommend  systematic  exercise,  active  massage,  and  hydro- 
pathic procedures.  Carlsbad  salts  and  thyroid  gland  substance  are  of- 
ten useful ;  some  cases,  however,  resist  all  sorts  of  treatment,  and  readily 
succumb  to  intercurrent  diseases. 

Adipositas  should  not  be  mistaken  for  cretinism  {q.  v,)  and  Frolich's 
Syndrome  {q.v.). 

Exudative  Diathesis 

This  symptom  complex,  first  fully  elucidated  by  Czerny,  is  quite  fre- 
quently observed  in  infants  of  certain  predisposed  families.  It  does 
not  seem  to  be  congenital  in  nature  although  some  clinicians  claim  to 
recognize  the  diathesis  in  the  newborn  by  a  prominent  comb-shaped  tuft 
of  hair  in  the  centre  of  the  scalp.  The  affection  is  characterized  by 
the  combination  of  inflammatory  symptoms  of  the  skin  and  mucous 
membranes,  as  follows:  (1)  The  skin:  transient  erythema,  intertrigo, 
urticaria,  prurigo,  blepharitis,  phlyctenular  conjunctivitis,  and  sebor- 
rheic eczema;  (2)  the  respiratory  tract;  recurrent  angina,  pharyn- 
gitis, copyza,  laryngitis  diffuse  bronchitis  and  tendency  to  asthma;  (3) 
the  alimentary  tract :  stomatitis,  lingua  geographica,  unprovoked  diar- 


522  DISEASES   OF    CHILDREN 

rhea  and  mucous  colitis.  Excepting  the  presence  of  marked  eosinophi- 
lia  (from  10  to  20  per  cent),  the  blood  shows  no  definite  alterations. 
The  nervous  system  is  but  slightly  involved  (vasomotor  disturbance, 
as  manifested  by  transient  flushing  of  the  face).  Some  authors  attrib- 
ute pavor  nocturnus,  spasmophilia  and  incontinentia  urinas  to  the 
exudative  diathesis.  The  general  appearance  of  the  baby  may  vary 
froin  puniness  to  obesity,  in  either  case  accompanied  by  muscular 
atony  and  general  lymphatic  enlargement. 

Czerny  attributes  the  condition  to  faulty  food  assimilation,  partic- 
ularly of  fat,  giving  rise  to  endogenous  nutritional  noxa  and  conse- 
quent increased  susceptibility  to  local  infections,  and  anaphylaxis. 
It  is  also  caused  by  ectogenic  nutritional  noxa,  resulting  from  over- 
feeding by  a  rich  diet,  be  it  proteins,  fats  or  carbohydrates.  In  some 
cases  the  food  idiosyncrasy  may  be  determined  by  the  "Allergy  test." 
(See  p.  87.) 

Treatment. — This  must  be  directed  principally  to  the  suitable  se- 
lection of  the  dietary.  The  supply  of  milk,  even  to  the  very  young 
infant,  must  be  limited  to  the  bare  necessity  of  life,  paying  particular 
attention  to  elimination  of  fat.  The  milk  at  all  times  should  be  diluted 
with  cereal  gruels.  Older  babies  should  be  fed  on  cereals,  well-boiled 
vegetables  and  bread,  and  but  little  milk.  Fruit,  raw  or  cooked,  is  al- 
lowed. Careful  attention  should  be  paid  to  the  nose  and  throat,  and  to 
the  skin.    Outdoor  air,  preferably  in  the  country. 

Acidosis 

(Recurrent,   Cyclic,  Periodic,  Vomiting.     "Acid  Intoxication") 

Cautley  defines  acidosis  as  "an  abnormal  metabolism  of  carbon,  lead- 
ing to  the  appearance  of  organic  acids  in  the  blood  and  urine,  and  the 
formation  of  ammonia  to  neutralize  the  acids."  The  chief  evidences  of 
acidosis  are  the  presence  of  acetone  bodies  (acetone,  diacetic  acid, 
beta-oxybutyric  acid)  in  the  urine,  diminished  alkalinity  of  the  blood 
(as  readily  determined  by  the  phenolsulphonephthalein  test)  and  reduced 
CO2  tension*  in  the  alveolar  air  (tested  by  the  Plesch-Howland  appara- 
tus). It  is  well  to  remember,  however,  that  the  presence  of  acetone  bodies 
in  the  urine  is  not  pathognomonic  of  acidosis  alone,  since  they  are  not 
rarely  observed  in  acute  febrile  diseases,  starvation  and  cachexia,  acute 
yellow  atrophy  of  the  liver,  and  delayed  anesthesia  poisoning.  The 
cause  of  acidosis  is  still  awaiting  definite  solution.  Ewing  suggests 
that  acidosis  is  due  to  disturbance  of  fat  metabolism,  caused  by  de- 


*Normal  tension  is  about  45  mm.  Hg.,  equaling  6  per  cent  CO2;  anything  below  30  mm.  is  an 
indication  of  acidosis. 


DISTURBANCES   OP    METABOLISM  523 

ficient  hepatic  function  associated  with  the  absorption  of  alimentary 
toxins.  Mellanby  believes  acidosis  to  be  caused  by  derangement  of 
the  glycogen  function  of  the  liver,  leading  to  imperfect  metabolism  of 
the  fats  with  formation  of  the  aforementioned  acids  as  intermediary 
products  and  imperfect  protein  metabolism  and  creatin  formation  due 
to  carbohydrate  insufficiency.  In  view  of  the  fact  that  acidosis  has 
occasionally  been  met  in  epidemic  form,  some  authors  are  inclined  to 
attribute  it  to  an  obscure  systemic  infection  or  a  species  of  toxemia. 
According  to  C.  H.  Dunn,  acidosis  prevailed  around  Boston  in  the 
winter  of  1915  and  1916,  but  he  thinks  it  was  symptomatic  of  a  grip- 
like infection  of  the  upper  air  passages. 

Acidosis  is  most  common  in  children  from  two  to  five  years  old.  It 
is  manifested  clinically  by  sudden  attacks  of  vomiting,  anuria,  pros- 
tration, sopor,  and  hyperpnea.  The  respirations  may  reach  up  to  sixty 
per  minute,  yet  be  free  from  dyspnea  and  cyanosis  (the  patient's  lips 
are  usually  deep  red  in  color).  The  vomiting  recurs,  periodically, 
cyclically,  at  short  or  long  intervals,  is  incessant  and  uncontrollable, 
often  blood  and  bile  stained,  and  occasionally  so  intense  as  to  pro- 
duce alarming  hemorrhage  from  the  stomach.  The  vomitus  in  the 
beginning  has  a  "sweetish"  odor.  The  attacks  may  last  from  a  few 
hours  to  several  days,  and  abruptly  end  in  perfect  recovery  of  the 
patient  or,  exceptionally,  lead  to  a  fatal  issue,  particularly  if  not  prop- 
erly handled.  The  temperature  is  moderate  (except  when  the  acido- 
sis is  complicated  by  pyelitis  which  is  not  rarely  the  case  especially  in 
girls)  ;  the  pulse  at  first  somewhat  retarded,  and  the  blood  shows  a 
marked  leucocytosis.     Often  the  lips  are  bright  red. 

With  these  symptoms  in  view  there  ought  to  be  no  difficulty  to  ar- 
rive at  a  correct  diagnosis.  It  may,  however,  be  mistaken  for  appen- 
dicitis, recurrent  uremia  from  chronic  nephritis,  and  tuberculous  men- 
ingitis, all  of  which  diseases  of  course  have  pathognomonic  symptoms 
of  their  own. 

Treatment. — After  brisk  catharsis  (calomel  gr.  ii),  stop  all  liquids  by 
mouth.  An  attempt  may  be  made  to  give  bicarbonate  of  soda  in  10 
grain-doses  (by  putting  it  dry  on  the  tongue  and  letting  it  melt  in 
the  mouth)  every  hour  or  two,  to  counteract  the  acidity,  but  if  it  is 
promptly  rejected,  it  is  best  left  alone,  and  administered  by  rectum 
instead  (1  ounce  of  bicarbonate  of  soda  in  1  pint  of  warm  water).  The 
irrigation  should  be  repeated  every  four  hours  and  followed  half  an 
hour  later  by  nutrient  enemas  consisting  of  a  5  per  cent  dextrose  so- 
lution, 4  ounces  at  a  time.  If  dextrose  is  not  obtainable,  saccharose  may 
be  used  instead.  Occasionally,  we  may  succeed  in  arresting  the  vomit- 
ing by  administering  Y^q  grain  of  codeine  sulphate  (without  water) 


524  DISEASES    OP    CHILDREN 

every  four  hours.  Hot  moist  packs  to  induce  diaphoresis  often  act 
beneficially.  After  the  vomiting  has  ceased  for  about  twelve  hours, 
Ave  may  begin  feeding  by  mouth,  giving  a  teaspoonful  to  a  tablespoon- 
ful  of  the  dextrose  solution  every  two  hours;  later  zwieback,  soda  bis- 
cuits, or  toast,  cereals  with  small  quantities  of  skimmed  milk,  and 
gradually  resume  the  regular  diet.  During  the  intervals  between  the  at- 
tacks, overfeeding  should  be  avoided  and  the  use  of  fats  restricted. 

Test  for  Acetone  and  Diacetic  Acid. — Test  solution  consists  of  10 
grams  glacial  acetic  and  10  c.c.  of  1 :10  solution  of  sodium  nitro- 
prusside.  Add  20  drops  of  this  reagent  to  15  c.c.  of  filtered  urine  in 
a  test  tube.  Overlay  the  mixture  with  ammonia  Avater.  The  presence 
of  acetone,  even  1  part  in  2,000,  causes  a  purple  ring  at  the  surface, 
separating  the  two  fluids.  Dilute  urine  wath  4  parts  of  water,  add 
drop  by  drop  solution  of  ferric  chloride  diluted  1:10.  Normal  urine 
or  that  containing  acetone  will  show  a  cloudj'  white  precipitate.  Presence 
of  diacetic  acid,  even  1/10,000,  gives  a  purplish  black  cloudy  precipitate. 


CHAPTER  IX 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

CONGENITAL  HEART  DISEASE 

(ViTiuM  Cordis) 

As  a  rule,  infants  born  with  heart  disease  are  very  delicate.  Most 
of  them  are  born  asphyxiated  and  if  resuscitated  remain  cyanotic/ 
or  very  anemic,  atelectatic,  cry  feebly,  breathe  superficially  and  very  rap- 


Fig.  152.— Vitium  cordis.  "Morbus  eoerulcus."  Note  "club-shaped"  fingers 
and  cyanosis  (represented  by  dark  patches  on  face  and  lips),  in  a  child  eight  years 
old. 


^From  time  immemorial  cyanosis  (morbus  coeruleiis  or  "blue  sickness  )  has  been  looked  upon 
as  a  cardiivil  symptom  of  congenital  heart  disease.  It  is  usually  associated  with  clubbing  ot  tne 
fingers  and  toes.  Its  diagnostic  importance  has  been  greatly  exaggerated,  since  it  is  not  rareiy 
absent  in   the   severest   forms   of   congenital   vitium   cordis. 

525 


526  DISEASES   OF    CHILDREN 

idly,  are  barely  able  to  suckle,  present  a  very  weak  pulse  and  subnormal 
temperature.  Not  rarely  they  are  born  prematurely*  and  with  congenital 
defects  of  other  parts  of  the  body.  Some  children  present  a  club-shaped 
appearance  of  the  fingers  and  toes  at  an  early  age ;  some  of  them  later. 
If  they  survive  for  any  length  of  time,  their  growth  and  development 
are  very  much  delayed.  They  are  helpless,  begin  to  hold  up  the 
head  or  sit  up  at  a  much  later  age  than  the  normal  baby.  When  they 
start  to  walk  they  tire  very  rapidly.  They  rarely  creep  and  when  on 
the  floor  are  often  unable  to  lift  themselves.  They  are  very  suscep- 
tible to  colds,  and  once  taken  sick,  they  are  very  slow  to  recuperate. 
Bottle-fed  babies  frequently  succumb  to  gastrointestinal  diseases,  even 
of  comparatively  simple  nature.  If  they  live  up  to  school  age  and 
are  more  frequently  exposed  to  acute  contagious  and  infectious  dis- 
eases, their  weakened  constitution  forms  a  favorable  nidus  for  the 
contraction  of  these  affections,  and  is  rarely  able  to  withstand  them. 

Even  under  the  best  of  care,  children  with  congenital  heart  disease 
usually  live  but  a  few  years.  Death  sometimes  occurs  suddenly,  or 
incidentally  in  the  course  of  other  diseases  which  in  normal  children 
are  not  dangerous  to  life,  especially  respiratory  affections.  Unless 
the  heart  defect  is  very  mild  in  nature,  children  with  vitium  cordis 
rarely  survive  the  age  of  puberty. 

The  course  of  congenital  heart  disease  varies,  of  course,  with  the  se- 
verity of  the  defect,  but  practically  resembles  that  of  acquired  vitium 
cordis,  which  is  fully  described  in  other  parts  of  this  treatise.  The 
following  are  the  most  common  congenital  heart  affections. 

•  Persistence  of  the  Foramen  Ovale 

This  condition  is  the  result  either  of  faulty  construction  of  the  fora- 
men or  its  valves,  or  defects  in  other  portions  of  the  heart  {e.  g.,  steno- 
sis of  the  pulmonary  artery)  which  by  indirect  blood  pressure  prevent 
complete  obliteration  of  the  foramen. 

It  is  the  most  frequent  kind  of  congenital  heart  disease,  but  is  not  al- 
ways recognizable  during  life.  In  the  presence  of  clinical  symptoms 
the  diagnosis  may  be  based  upon  preponderance  of  cyanosis,  a  sys- 
tolic blowing  sound  at  the  base  of  the  heart  or  over  the  third  or  fourth 
costal  cartilage. 

Persistence  of  the  Ductus  Arteriosus  Botalli 

Complete  obliteration  of  this  duct  is  supposed  to  occur  by  the  end 
of  the  third  month.     This  may  be  retarded  or  may  entirely  fail— 

*See  "Feeble  Vitality  of  the  Newborn,"  p.  213. 


DISEASES   OF    THE    CIRCULATORY    SYSTEM  527 

usually  in  cases  where  the  left  ventricle  is  not  properly  filled  with 
each  heart  c^'cle  {e.g.,  in  atelectasis,  fetal  pneumonia,  stenosis  of  the 
pulmonary  artery),  in  which  event  the  blood  from  the  pulmonary  ar- 
tery continues  to  flow  through  the  ductus  arteriosus  to  the  insufficiently 
filled  aorta.  As  a  result  of  this  anomaly  there  develops  sooner  or 
later  hypertrophy  of  the  right  ventricle  usually  with  dilatation  of  the 
pulmonary  artery. 

The  symptomatology  is  very  variable.  In  cases  of  only  partial  pa- 
tency the  symptoms  may  be  so  slight  as  to  escape  observation.  Com- 
plete patency  of  the  duct  very  gradually  gives  rise  to  the  following 
group  of  symptoms:  disposition  to  respiratory  affections,  cyanosis, 
or  waxy  pallor,  dyspnea,  cool  extremities,  palpitation,  a  thrill  over  the 
anterior  chest  wall,  increased  cardiac  dulness  to  the  right,  accentua- 
tion of  the  second  pulmonic  sound  which  can  also  be  heard  in  the 
carotids,  loud,  buzzing,  systolic  murmur  over  the  precordium,  often 
epistaxis  or  hemorrhage  from  other  mucous  membranes,  and  finally, 
sometimes  not  until  after  several  years  of  existence,  marked  symptoms 
of  failure  of  compensation  with  rapid  fatal  determination. 

Defects  in  the  Septum  Ventriculormn 
(Communication  of  the  Ventricles) 

It  is  a  very  common  condition,  most  frequently  the  result  of  fetal 
myocardial  diseased  processes,  and  not  rarely  coexisting  with  con- 
genital stenosis  of  the  pulmonary  artery.  The  defect  is  situated  either 
in  the  anterior  or  posterior  portion  of  the  septum.  Very  rarely  the 
whole  wall  between  the  ventricles  and  auricles  is  absent,  so  that  all 
four  heart  cavities  communicate. 

Accentuation  of  the  second  pulmonic  sound ;  overfilling  of  the  veins ; 
marked  cyanosis  developing  soon  after  birth  or,  more  gradually,  some- 
time after ;  and  hypertrophy  and  dilatation  of  the  right  ventricle,  all 
point  to  a  defect  of  the  ventricular  septum.  A  positive  diagnosis,  how- 
ever, is  almost  impossible  during  the  life  of  the  patient. 

The  prognosis  is  very  bad. 

Congenital  Stenosis  of  the  Pulmonary  Artery 

The  stenosis  may  involve  the  orifice  alone,  the  entire  trunk,  or  the 
branches  of  the  pulmonary  artery.  Accordingly  the  symptomatology 
varies  with  the  extent  and  location  of  the  lesion.  As  a  rule,  there  is 
marked  cyanosis  from  birth.  Some  children  are  born  asphyxiated,  and 
if  resuscitated,  continue  to  suffer  from  attacks  of  sut¥ocation  and  con- 
vulsions, to  which  they  usually  succumb  within  the  first  few  days 


528  DISEASES   OP    niirvDREN 

of   life.      Stronger   children   may    survive    these    attacks,    o^ain    some 
strenoth,  lose  part  of  the  cyanosis  and  live  several  years. 

Physical  examination  reveals  arching  of  the  anterior  left  chest  wall, 
enlargement  of  the  cardiac  area,  chiefly  to  the  right,  a  diffuse  systolic 
murmur,  heard  loudest  over  the  left  and  third  costal  cartilages,  and 
often  a  purring  thrill  on  palpation.  The  blood  usually  shows  a  marked 
increase  in  the  luimber  of  erythrocj'tes  and  a  high  hemoglobin  index. 

Congenital  Stenosis  of  the  Tricuspid  Valve 

It  is  usually  the  result  of  an  anomalous  or  excessive  development  of 
the  muscle  substance  of  the  valve,  or  of  fetal  endocarditis,  and  is  often 
associated  with  other  congenital  heart  defects. 

The  sj-mptomatology  resembles  that  of  defects  of  the  pulmonary 
artery,  except  that  the  murmur  is  heard  loudest  over  the  fourth  and 
fifth  costal  cartilages,  and  hypertrophy  of  the  right  side  is  either 
absent  or  very  slight. 

The  prognosis  is  unfavorable. 

Congenital  Stenosis  of  the  Ostium  Atrioventriculare  Sinistrum 

(Stenosis  of  the  Aorta) 

The  stenosis  may  be  situated  at  the  point  of  origin  of  the  aorta ;  at 
any  place  throughout  the  entire  aortic  system ;  or  at  the  ductus  Botalli. 

As  a  result  of  either  one  of  the  aforementioned  conditions  there  is 
hypertrophy  of  the  left  heart.  Varying  with  the  seat  of  the  atresia, 
the  blood  vessels  above  the  lesion  may  be  abnormally  filled  with  blood, 
while  those  emerging  below  the  lesion  suffer  from  a  deficiency  of  it. 
Between  the  two  groups  of  vessels  a  collateral  circulation  is  usually 
established  which  may  frequently  be  recognized  by  numerous,  visible, 
actively  pulsating,  subcutaneous  blood  vessels  over  the  thorax.  A  sys- 
tolic murmur  is  often  heard  over  the  dilated  arteries.  The  heart  is 
usually  free  from  any  auscultatory  signs,  unless  the  orifice  of  the  aorta 
be  involved,  when  a  loud  systolic  murmur  may  be  heard  at  midsternum. 

The  patient  may  live  for  several  years — until  compensation  rup- 
tures. Death  sometimes  ensues  very  suddenly  from  rupture  of  a  group 
of  vessels  above  the  stenosis. 

Treatment. — The  treatment  of  congenital  heart  disease  is  practically 
the  same  as  that  of  acquired  and  is  fully  outlined  on  p.  540.  Complete 
rest  in  the  strictest  sense  of  the  word  will  help  to  prolong  life — possi- 
ly  to  an  advanced  age. 


DISEASES   OF    THE    CIRCFLATORY    SYSTEM 


529 


Dextrocardia 

Among  the  few  congenital  malpositions  of  the  heart  {mesocardia— 
the  heart  occupies  a  central  position  of  the  chest  wall ;  ectopia  cordis — 
the  heart  may  be  situated  either  between  a  fissure  in  the  sternum  im- 
mediately beneath  the  skin,  in  the  neck  or  in  the  abdomen  below  the 
diaphragm),  dextrocardia  (see  Fig.  153),  or  transposition  of  the  lieart 
to  the  right  side,  is  of  special  interest  inasmuch  as  it  very  rarely  inter- 
feres wuth  the  life  or  welfare  of  the  patient.  Dextrocardia  is  often 
associated  with  a  general  transposition  of  the  viscera.     The  aorta  and 


Fig.   153. — Dextrocardia   in  a  girl   six  years   old.     Posterior   view. 

its  branches  usually  remain  in  their  normal  situation.  Dextrocardia 
should  not  be  confounded  with  displacement  of  the  heart  by  large  ef- 
fusions or  growths  in  the  thoracic  cavity. 


ACQUIRED  HEART  DISEASE 

Myocarditis 

Degeneration  of  the  muscular  tissue  of  the  heart  is  occasionally 
congenital,  a  sequel  of  infection  during  fetal  life,  but  most  frequently 
acquired,  occurring  either  secondarily'  to  acute  infectious  diseases,  or 


530  DISEASES   OF    CHILDREN 

as  a  result  of  extension  of  an  inflamination  of  the  inner  or  outer  lining 
of  the  heart. 

The  inflammation  may  be  diffuse  or  circumscribed,  and  as  in  adults, 
either  plastic  or  interstitial,  or  degenerative  or  parenchymatous. 

The  interstitial  variety  of  myocarditis  usually  leads  to  suppuration 
and  abscess  formation  of  the  musculature.  In  parenchymatous  myo- 
carditis the  transverse  striae  of  the  fibrillge  appear  lost,  the  muscle 
consisting  chiefly  of  fatty  and  granular  substances. 

The  course  of  the  disease  varies  greatly  with  the  underlying  cause 
and  the  rapidity  of  the  inflammatory  process. 

In  the  majority  of  instances  interstitial  myocarditis  is  complicated 
by  endocarditis  and  pericarditis,  and  hence  it  is  very  seldom  possible 
early  to  diagnose  the  existence  of  the  myocarditis.  In  cases  where  the 
inflammation  is  circumscribed,  myocarditis  may  be  surmised  by  the 
sudden  precordial  pain,  dyspnea,  high  fever,  restlessness  and  delirium. 
The  apex  beat  and  pulse  are  weak,  arrhythmic  and  rapid.  Death  is  the 
usual  termination;  not  rarely  occurring  suddenly  with  symptoms  of 
sudden  collapse. 

Parenchymatous  myocarditis  ordinarily  runs  a  slow  and  latent 
course.  Occasionally,  however,  the  degenerative  process  develops  quite 
rapidly.  Extreme  pallor,  breathlessness,  and  weak  and  galloping  pulse 
point  to  the  involvement  of  the  myocardium,  but  in  the  early  stages 
the  diagnosis  can  rarely  be  made  with  any  degree  of  certainty.  As 
the  disease  advances  and  symptoms  of  cardiac  dilatation  and  passive 
pulmonary  congestion  set  in,  the  diagnosis  is  fairly  certain. 

The  treatment  is  the  same  as  in  endocarditis  (q.  v.) 

Pericarditis 

Primary  pericarditis  is  usually  due  to  a  streptococcus  or  pneumococcus 
infection  through  the  blood  or  lymph  channels  or  in  connection  with 
acute  articular  rheumatism.  Like  pleuritis,  inflammation  of  the 
pericardium  may  occur  in  dry  form  or  with  an  effusion.  The  exu- 
dation may  be  serofibrinous,  hemorrhagic,  or  purulent.  Dry,  as 
well  as  exudative,  pericarditis  may  give  rise  to  inflammatory  adhesions 
between  the  pericardium  and  the  heart,  and  occasionally  to  the  an- 
terior and  posterior  chest  walls  and  vertebral  column. 

The  gravity  of  this  affection  should,  therefore,  not  be  underesti- 
mated. The  prognosis  is  serious,  especially  in  the  secondary  variety 
occurring  in  connection  with  tuberculosis,  septic  processes,  pleuro- 
pneumonia, caries  of  ribs  or  vertebrae,  severe  exanthematous  diseases 
(e.  g,,  scarlatina),  purpura  hemorrhagica,  chronic  nephritis,  etc.  It  is 
less  dangerous  in  primary,  usually  rheumatic  form,  particularly  if  the 


DISEASES   OF    THE    CIRCULATORY    SYSTEM  531 

patient  is  over  three  years  of  age,  or  when  caused  by  syphilis  and  is  de- 
tected and  treated  early. 

Bearing  in  mind  the  etiologic  factors  just  enumerated,  we  can 
readily  appreciate  that  pericarditis  in  children  must  be  quite  com- 
mon. Indeed,  there  is  ample  reason  for  the  belief  that  in  children 
over  three  years  of  age  pericarditis  is  almost  as  frequent  as  endo- 
carditis, with  w^hich  affection,  by  the  way,  it  is  not  rarely  associated. 

The  onset  of  primary  pericarditis  is  usually  very  sudden,  but  some- 
times, like  the  secondary  variety,  it  may  be  insidious.  Ordinarily  it 
is  ushered  in  with  high  temperature,  vomiting,  cardiac  oppression,  or- 
thopnea, dyspnea,  and  accelerated  pulse.  Cough  is  an  early  symptom, 
and,  in  the  presence  of  an  effusion,  quite  pronounced.  This  symptom 
is  probably  due  to  cardiac  pressure  against  the  lungs.  The  pulse,  which 
in  dry  pericarditis  is  strong,  is  often  very  feeble,  barely  perceptible, 
and  irregular  in  marked  exudative  pericarditis.  Pain  is  frequently 
intense,  especially  if  associated  with  polyarthritis.  The  patient  is 
restless,  sleepless,  the  expression  of  his  face  anxious,  and  denoting  great 
suffering.  Of  course,  the  symptomatology  is  greatly  modified  by  that 
of  the  underlying  affection,  if  existing. 

The  physical  signs  vary  with  the  stage  of  the  disease.  Before  the 
development  of  the  effusion,  auscultation  elicits  superficial,  exocar- 
dial,  to-and-fro  friction  and  creaking  sounds,  limited  over  the  cardiac 
region,  often  changeable  with  the  position  of  the  patient  and  audible 
independently  of  the  heart  sounds.  Friction  fremitus  may  be  felt  over 
the  area  where  the  friction  murmur  is  heard.  Endocardial  murmurs 
may  coexist.  When  serous  effusion  occurs  the  friction  sound  is  found 
diminished  or  absent,  the  heart  impulse  very  feeble,  whereas  the 
pulse  may  be  felt  quite  strong,  and  the  respiratory  movements  of  the 
left  side  of  the  chest  are  diminished.  The  area  of  heart  dulness  is  greatly 
increased  laterally  and  vertically,  pushing  the  edges  of  the  lungs  aside 
so  that  the  entire  sternal  region  is  dull  on  percussion.  When  the 
effusion  is  large,  we  can  also  note  distinct  bulging  of  the  cardiac  area 
of  the  chest.  According  to  Rotch,  the  liver  is  depressed  and  a  dull 
note  is  obtained  in  the  right  fifth  intercostal  space.  He  considers  this 
a  sign  of  great  importance  in  the  differentiation  of  pericardial  effusion 
from  cardiac  dilatation,  since  in  a  dilated  heart  the  dulness,  he  thinks, 
never  reaches  the  fifth  interspace. 

There  are  several  other  distinctive  features  which  render  the  dif- 
ferentiation of  pericardial  effusion  from  enlarged  heart  possible.  Thus, 
in  dilatation  or  hypertrophy  of  the  left  ventricle,  the  apex  beat  is  felt 
at  the  extreme  left  limit  of  the  dulness  (outside  the  mammary  line) 
and  at  its  lowest  level,  while  in  effusion  the  apex  beat,  or  rather  the 


532  DISEASES   OF    CHILDREN 

heart  impulse,  is  at  a  spot  inside  and  above  the  boundaries  of  the  car- 
diac dulness,  somewhere  between  the  fourth  and  tliird  interspace. 
In  pericarditis  the  dulness  develops  much  more  acutely  than  in  an 
enlarged  heart,  which  latter  occurs  secondarily  to  more  or  less  chronic 
valvular  disease.  However,  we  should  bear  in  mind  that  pericarditis, 
acute  or  chronic  endocarditis,  and  hypertrophj'  and  dilatation  may  co- 
exist and  give  rise  to  a  symptom  complex  beyond  the  possibility  of  in- 
dividualization. For  further  differentiation  between  pericarditis  and 
endocarditis  the  reader  is  referred  to  the  discussion  of  the  latter  af- 
fection.   (See  p.  536.) 

With  absorption  of  the  fluid  in  the  pericardium  there  is  a  gradual 
return  of  the  symptoms  of  the  first  stage  and,  in  favorable  cases, 
restitutio  ad  integrum,  or  quite  frequently,  supervention  of  pericardial 
adhesions  with  consecutive  systolic  retraction  of  the  chest  wall  over  the 
entire  precordium. 

The  nature  of  the  effusion  can  readily  be  ascertained  by  exploratory 
puncture,  but  even  without  it  we  may  surmise  the  presence  of  pus  if  the 
pericarditis  develops  secondarily  to  septic  processes ;  blood,  after  severe 
trauma,  and  serum,  in  primary,  usually  rheumatic,  pericarditis.  An 
x-ray  examination  is  often  of  service.  The  determination  of  the  charac- 
ter of  the  effusion  is  important  especially  as  regards  the  further  course 
and  treatment  of  the  disease. 

Rheumatic  pericarditis,  if  free  from  complications,  lasts  from  two 
to  three  w^eeks  or  longer.  After  about  ten  days  there  is  a  gradual 
evanescence  of  the  symptoms.  Not  infrequently,  however,  the  ap- 
parent recovery  is  only  temporary,  inasmuch  as  there  may  be  a  return 
of  the  effusion,  or  development  of  valvular  deposits,  which  sooner  or 
later  give  rise  to  marked  valvular  disease.  These  manifestations  are 
particularly  prone  to  occur  in  pericarditis  with  polyarthritis.  Peri- 
carditis, like  endocarditis,  not  rarely  precedes  the  joint  symptoms,  may 
run  a  latent  course  and  if  mild  in  character  disappear  again  without 
being  detected,  possibly  not  until  repeated  recurrences  and  appear- 
ance of  complications.  More  rarely,  pericarditis  ends  in  death  either 
rapidly  as  a  result  of  cardiac  muscular  insufficiency  and  pulmonary 
edema,  or  more  slowly  from  early  complications,  such  as  pleurisy,  pneu- 
monia, severe  adhesions,  endocarditis,  etc. 

Purulent  pericarditis  pursues  a  much  more  violent  course.  Extreme 
fatigue,  severe  attacks  of  syncope  and  pyemic  fever  predominate,  while 
the  local  symptoms  are  comparatively  insignificant.  Even  the  exuda- 
tion is  often  slight.  When  it  occurs  in  conjunction  with  tuberculosis, 
it  is  very  malignant  in  character.  It  is  then  manifested  by  enormous 
hypertrophy  of  the  pericardium,  extensive  adhesions,  laTge  quantities 


DISEASES   OF    THE    CIRCl'LATORY    SYSTEM  533 

of  pus  between  the  heart  and  pericardium,  and  numerous  tubercles 
in  the  latter.  It  is  invariably  fatal.  The  same  holds  true  for  pyemic 
pericarditis,  in  which  streptococci,  pneumococci,  staphylococci  and 
less  frequently,  gonococci  act  as  the  principal  exciting  cause. 

Treatment. — A  disease  presenting  so  many  phases  as  pericarditis, 
can  at  best  be  treated  only  symptomatically.  Absolute  rest  in  bed, 
liquid  diet  (thin  cereals,  vegetable  soups,  fermented  milk),  an  ice 
bag  (not  too  heavy  and  preferably  on  top  of  a  layer  of  lint),  to  the 
precordium,  and  sodium  salicylate  (1  grain  for  ever}-  year  of  the  child's 
age  every  two  hours)  and  codeine  {Y^o  grain  every  six  hours)  inter- 
nally will  often  do  well  in  rheumatic  cases.  In  large  pericardial  ser- 
ous effusions  wath  threatening  syncope  we  may  try  free  diuresis  and 
saline  catharsis  wnth  or  without  aspiration  (in  the  fifth  intercostal 
space  a  little  to  the  left  of  the  border  of  the  sternum).  The  latter 
procedure  frequently  proves  useful  also  in  small  nontuberculous  puru- 
lent effusions,  while  in  large  purulent  effusions  incision  and  drainage 
are  preferable  to  aspiration.  In  these  cases  some  benefit  may  be  de- 
rived from  vaccines. 

In  quite  a  number  of  cases  sodium  iodide  in  from  3  to  5  grain  doses, 
t.i.d.,  seems  to  exert  a  specific  effect;  and,  bearing  in  mind  also  the 
possibility  of  underlying  syphilis,  we  should  always  administer  this 
remedy  irrespective  of  the  variety  of  the  pericarditis  and  the  mode  of 
treatment  simultaneously  employed.  Digitalis  or  strophanthus  may  be 
given  to  strengthen  the  heart,  if  cardiac  weakness  sets  in,  w^hich  is 
apt  to  occur  later  in  the  course  of  the  disease. 

Chronic  pericarditis  is  productive  of  grave  disturbances  of  the  cir- 
culation, cardiac  hypertrophy,  and  dilatation.  Myocarditis  is  a  fre- 
quent sequela.  See  also  ''Congestive  Cirrhosis"  and  "Sugar-Cake 
Liver". 

Endocarditis  Acuta 

The  etiologic  factors  of  acute  endocarditis  are  essentially  the  same  as 
in  pericarditis  {q.  v.)  except  that  the  former  is  more  frequently  asso- 
ciated with  rheumatic  affections,  such  as  arthritis,  chorea,  tonsillitis, 
erythema  nodosum,  etc.,  and  not  rarely  complicates  pericarditis.  In- 
vasion of  the  endocardium  by  the  streptococcus,  staphylococcus,  pneu- 
mococcus,  the  bacillus  pyocyaneus,  tubercle  bacillus,  and  gonococcus 
usually  occurs  through  the  circulating  blood,  giving  rise  to  a  patho- 
logic condition  very  similar  to  that  observed  in  adults. 

The  inflammation,  which  is  usually  limited  to  the  left  side  of  the 
heart  (in  the  fetus  the  right  side  is  mostly  affected),  first  attacks  the 
vascular,  layer  of  the  endocardium  between  the  muscular  and  fibrous 
coats,  resulting  in  an  exudation  of  lymph  and  serum  principally  be- 


534 


DISEASES   OF    CHILDREN 


neath  and  on  the  free  surface  of  the  membrane  covering  the  valves 
and  chordae  tending.  As  the  disease  progresses,  large  or  small  papil- 
lary nodules,  vegetations,  are  formed  on  the  endocardium — endocardi- 
tis verrucosa;  or  ulcerations  may  occur  as  a  result  of  destruction  of 
the  superficially  necrosed  tissue — endocarditis  ulcerosa.  The  latter 
condition  is  usually  found  in  the  malignant,  usually  septic,  form  of 
endocarditis.  During  the  course  of  endocarditis  the  pericardium  and 
myocardium  become  involved  and  many  organs  of  the  body,  e.  g., 
the  kidneys,  spleen,  brain,  etc.,  may  become  implicated  through  em- 
boli composed  of  masses  of  fibrin  or  necrosed  tissue  which  become 
detached  by  the  circulating  blood,  principally  from  the  irregular  val- 
vular  deposits.     In   septic   cases  these   emboli   give   rise   to    abscesses. 


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Fig.  154. — Fever  curve  of  malignant  endocarditis  in  a  child  three  years  old. 


It  is  well  to  remember,  however,  that  moderately  severe  cases  of  endo- 
carditis may  go  on  to  complete  recovery  and  leave  no  trace  of  the 
original  inflammation  on  the  endocardium;  furthermore,  that  slight 
valvular  vegetations  are  not  infrequently  found  postmortem  without 
any  apparent  clinical  signs  of  heart  disease  during  life.  This  latter 
observation  can  readily  be  explained  by  the  fact  that  mild  endocarditis 
is  not  rarely  masked  by  the  course  of  another  disease  and,  unless 
presenting  marked  disturbance  of  the  circulation,  is  very  apt  to  be 
overlooked.  More  often,  of  course,  endocarditis  sets  in  with  severe 
unmistakable  symptoms.  The  patient  vomits,  suffers  from  chills, 
more  or  less  high  fever   (102°  to  105°   F,),  precordial  distress,  short 


DISEASES   OF    THE    CIRCULATORY   SYSTEM  535 

cough,  dyspnea,  and  accelerated,  sometimes  irregular,  pulse.  These 
symptoms,  however,  are  not  sufficiently  characteristic  of  endocarditis 
and  may  still  leave  the  nature  of  the  disease  obscure  until  the  sub- 
sequent appearance  of  local  signs,  especially  of  a  systolic  heart  mur- 
mur, audible  chiefly  at  the  apex  (the  mitral  valve  being  most  fre- 
quently involved  owing  to  its  great  vascularity)  or  also  over  the 
whole  cardiac  region.  Sometimes  endocarditis  follows  an  apparently 
mild  attack  of  tonsillitis  with  possibly  a  moderate  joint  involve- 
ment, with  or  without  signs  of  chorea.  As  will  be  seen  later  (see 
''Endocarditis  Chronica,"  p.  536),  murmurs  may  subsequently  develop 
at  the  various  orifices  of  the  heart,  and,  at  a  later  stage  of  the  disease, 
additional  physical  signs  (hypertrophy  or  dilatation)  may  be  obtained 
by  percussion. 

Occasionally  (in  children  less  frequently  than  in  adults)  acute  endo- 
carditis pursues  a  very  septic  and  often  violent  course — endocarditis 
maligna  {idcerosa) .  It  may  be  preceded  by  pneumonia,  exanthematous 
diseases,  septic  processes  in  some  other  parts  of  the  body,  e.  g.,  osteo- 
myelitis, etc.,  or  occur  without  any  apparent  cause  and  exhibit  a  symp- 
tom complex  resembling  either  a  low  typhoid  state  or  cardiac 
insufficiency  with  acute  dilatation  (cyanosis)  and  loud  murmurs  at  the 
various  orifices.  The  duration  of  malignant  endocarditis  varies.  Ordina- 
rily it  runs  a  protracted  course  with  irregular  temperature,  chills, 
rigors  and  sweats.  Sooner  or  later  emboli  develop  in  different  organs 
of  the  body  and  the  capillaries  of  the  skin,  the  superadded  symptoms 
varying,  of  course,  with  the  organ  affected.  Thus,  if  the  brain  is  in- 
volved, we  find  palsies  with  disorder  of  consciousness;  if  the  spleen,  en- 
largement of  this  organ  and  tenderness;  if  the  kidneys,  albuminuria, 
hematuria  and  anasarca ;  if  the  skin,  petechise  and  a  pustular  eruption. 
It  is  not  rarely  complicated  also  by  purulent  pericarditis.  When  malig- 
nant endocarditis  runs  so  very  violent  a  course  it,  as  a  rule,  terminates 
fatally  wathin  a  few  days.  On  the  other  hand,  simple,  benign  endo- 
carditis in  children  is  usually  not  dangerous  to  life.  If  free  from 
complications,  the  symptoms  begin  to  subside  after  about  a  week  or 
ten  days,  eventually  leading  to  recovery  in  about  four  weeks.  In  quite 
a  number  of  cases,  however,  it  is  followed  by  permanent  valvular  dis- 
ease, with  or  without  cardiac  hypertrophy.  (See  "Endocarditis 
Chronica,"  p.  536.)     Death  is  usually  due  to  cardiac  paralysis. 

Benign  endocarditis  may  be  mistaken  for  dry  pericarditis,  especially 
if  the  former  is  associated  with  articular  rheumatism.  The  following 
table  contrasts  the  most  important  distinguishing  features.  Both  dis- 
eases, however,  may  coexist. 


536  DISEASES   OF    CHILDREN 

Simple  Endocarditis  Dry  Pericarditis 

Blowing  or  musical  sound.  "To     and    fro"     friction     or     croaking 

sound. 

Sound  is  associated  wUh  systole  or  dias-  Not  necessarily.     May  ho  heard  at  any 

tole.  period  of  cycle. 

Sound  is  distant.  Near  to  the  ear. 

Sound  is  uninfluenced   by   pressure   with  Increased. 

the  stethoscope. 

Sound  is  conducted  upward,  to  the  ax  Not  so, 

ilia,  and  to  the  back. 

Sound  usually  loudest  at  apex.  Anywhere  over  precordium. 

The  diagnosis'  of  ulcerative  endocarditis  is  very  difficult,  especially 
in  the  incipient  stage,  before  the  appearance  of  a  heart  murmur. 
Whenever  several  orifices  are  the  seat  of  the  murmur,  paroxysms  of 
cyanosis,  prostration,  dyspnea,  and  irregular  temperature  predomi- 
nate and  cardiac  dulness  is  increased,  the  diagnosis  of  malignant 
endocarditis  is  justified.  The  elimination  of  typhoid,  irregular  mala- 
rial fever,  military  tuberculosis  and  pyemia,  the  four  affections  with 
which  malignant  endocarditis  is  most  apt  to  be  confounded,  will 
greatly  facilitate  the  diagnosis. 

Treatment. — The  treatment  of  endocarditis  is  essentially  the  same  as 
in  pericarditis — purely  symptomatic.  Absolute  rest  in  bed,  in  the  re- 
cumbent posture,  and  a  light  ice  bag  to  the  precordium.  Antirheu- 
matic remedies,  in  conjunction  with  small  doses  of  codeine  and  digi- 
talis to  strengthen  the  heart.  Light  (meat  free)  easily  assimilable 
diet.  Cool  sponging  for  high  temperature.  In  malignant  endocarditis 
some  benefit  may  be  derived  from  polyvalent  antistreptococcus  serum 
and  transfusion.  As  recurrent  endocarditis  is  not  rarely  due  to  per- 
sistent infection  of  the  nasopharynx,  it  is  always  in  order  to  use  a 
nose  and  throat  wash  a  few  times  daily,  irrespective  of  the  cause. 
(See  "Pericarditis,"  p.  533.) 

Endocarditis  Chronica 

(Valvular  Heart  Disease) 

Chronic  endocarditis  is  most  frequently  a  sequel  of  acute  inflam- 
mation of  the  endocardium  especially  of  the  valves,  and  pathologically 
consists  of  proliferation  and  thickening  of  the  valvular  connective 
tissue  with  a  great  tendency  to  contractions  and  adhesions  and  very 
rarely  to  calcification.  The  chronic  inflammatory  process  is  usually 
limited  to  the  left  side  of  the  heart  except  in  cases  developing  during 
fetal  life,  when  the  reverse  is  the  case. 

Coincident  with  the  inflammatory  process  in  the  endocardium,  the 


DISEASES   OF    THE    CIRCULATORY    SYSTEM 


537 


cardiac  musculature  undergoes  gradual  enlargement.  This  hyper- 
trophy, unless  assuming  exceptionally  large  dimensions  {e.g.,  cor 
bovium),  is  strictly  speaking  not  a  disease  per  se,  but  on  the  contrary, 
an  effort  on  the  part  of  nature  to  overcome  or  undo  the  evil  effects  of 
the  disease.    As  the  disease  advances  and  the  heart  muscles  lose  their 


Fig.  155. — ^Intense  flilatatign  of  the  heart  in  a  two-months-old  infant  suffering 
from  congenital  heart  disease  which  was  greatly  aggravated  by  an  attack  of  whoop- 
ing cough. 


power,  get  exhausted,  the  hypertrophy  is  replaced  by  dilatation,  indi- 
cating tl^at  compensation  has  "ruptured,"  and  that  the  disease  is  be- 
yond control. 


538  DISEASES   OF    CHILDREN 

Until  failure  of  compensation  has  occurred,  children  may  for  years 
remain  apparently  free  from  any  marked  distur])ances  of  health,  except 
perhaps,  an  indistinct  first  sound  at  the  apex,  an  unduly  bounding  pulse, 
throbbing  of  the  blood  vessels  in  the  neck,  rapid  fatigue,  palpitation  of 
the  heart  on  exertion,  progressive  anemia  and  malnutrition  notwith- 
standing good  appetite  and  digestion.  Indeed,  it  is  often  for  disturbance 
of  the  stomach  that  the  patients  are  brought  to  the  physician.  Shortness 
of  breath,  which  increases  on  exertion,  usually  forms  an  early  manifesta- 
tion of  failing  compensation.  It  is  the  result  of  stasis  in  the  pulmonary 
circulation  with  consecutive  impairment  of  aeration.  This  sooner  or  later 
leads  to  passive  congestion  of  the  pulmonary  alveoli  giving  rise  to  bron- 
chitis with  an  irritable  cough,  and  as  the  heart  failure  increases,  to 
paroxysmal  attacks  of  dyspnea  or  orthopnea  especially  at  night  ("car- 
diac asthma")  pulmonary  edema,  cyanosis,  and  occasionally  to  hemor- 
rhagic infarcts  in  the  lung  with  consecutive  hemoptysis. 

Simultaneously  with  the  aforementioned  manifestations  pathologic 
changes  go  on  also  in  other  internal  organs — the  liver,  spleen  and 
kidneys.  The  liver  and  spleen  are  enlarged,  and  by  pressure  upon 
neighboring  thoracic  and  abdominal  organs,  increase  the  dyspnea. 
As  a  sequel  of  the  passive  congestion  of  the  liver  and  stasis  in  the 
blood  vessels  of  the  stomach  and  intestines,  numerous  gastrointestinal 
disturbances — e.  g.,  anorexia,  vomiting,  constipation — develop,  which 
add  misery  to  the  patient's  painful  existence. 

The  changes  in  the  kidneys  are  manifested  by  diminution  in  the 
quantity  of  urine,  often  albuminuria  (slight),  hyaline  and  cylindrical 
casts,  and  occasionally  white  and  red  blood  corpuscles — signs  of 
passive  congestion. 

With  increasing  venous  stasis  there  is  coincident  transudation  of 
the  fluid  of  the  blood  from  the  capillaries  into  the  meshes  of  the 
tissues,  leading  to  edema.  At  first  the  dropsy  is  limited  to  the  ankles 
and  eyelids,  but  as  the  disturbance  of  circulation  advances  it  grows 
worse  and  involves  the  entire  integument  and  the  internal  cavities, 
especially  the  abdominal  and  pleural  cavities.  Notwithstanding  the 
extreme  gravity  of  the  condition,  the  end  is  not  always  as  near  as 
would  be  expected.  The  inherent  power  of  the  infantile  heart  is  still 
capable  of  temporary  reparation.  The  arrhythmia,  dyspnea,  and 
dropsy  may  disappear ;  the  appetite  and  nutrition  may  improve ;  the 
tottering  patient  may  again  be  up  and  around,  in  fact,  may  appear 
at  his  best. 

Exacerbations  and  improvements  of  the  disease  may  recur  several 
times.  The  improvement,  as  a  rule,  is  but  short  lived.  Very  soon  the 
symptoms  return,  and  generally  with  greater  severity.     Finally,  after 


DISEASES    OF    THE    CIRCULATORY    SYSTEM  539 

a  more  or  less  prolonged  period  of  illness  the  patient  succumbs  to 
heart  failure.  Occasionally,  death  occurs  suddenly  after  severe  ex- 
ertion. Quite  a  number  of  children  are  carried  away  by  intercurrent 
infectious  diseases,  pericarditis  or  recurrent  acute  endocarditis.  The 
physician  should  therefore  always  be  very  guarded  in  the  prognosis. 
The  relative  gravity  of  valvular  lesions  is  as  follows:  Tricuspid  re- 
gurgitation ;  mitral  regurgitation ;  mitral  stenosis ;  aortic  regurgitation ; 
pulmonic  stenosis;  aortic  stenosis. 

Differential  Diagnosis* 

As  the  physical  signs  of  valvular  heart  disease  in  children  differ 
but  little  from  those  in  adults,  we  will  briefly  review  only  the  most 
essential  differential  points  of  diagnosis. 

Mitral  Regurgitation. — Insufficiency  of  the  mitral  valve  is  char- 
acterized by  a  systolic  blowing  murmur  which  is  loudest  at  the  apex 
and  transmitted  to  the  axilla  and  near  the  lower  angle  of  the  left 
scapula.  Accentuation  of  the  second  pulmonic  sound.  Hypertrophy 
of  the  left  ventricle,  and  later  left  auricle,  and  sequential  hypertrophy 
of  the  right  ventricle.  The  pulse  may  be  normal  or  accelerated,  and 
with  disturbed  compensation — which  may  not  occur  for  many  years — 
irregular  and  unequal. 

Mitral  Obstruction. — It  is  frequently  associated  with  insufficiency. 
The  murmur  is  usually  presystolic  or  also  diastolic,  is  best  heard  at 
the  apex,  and  may  be  conveyed  to  the  fourth  interspace,  but  never 
to  the  angle  of  the  scapula.  The  pulmonic  second  sound  is  accentu- 
ated and  sometimes  double.  It  frequently  leads  to  hypertrophy  of 
the  left  auricle  and  right  ventricle. 

Aortic  Regurgitation. — Aortic  insufficiency  is  rare  in  children.  It 
is  accompanied  by  hypertrophy  of  the  left  ventricle,  and  often  pulsa- 
tion of  the  arteries  of  the  neck.  The  murmur  is  diastolic,  loudest  at 
the  insertion  of  the  right  second  costal  cartilage  and  over  the  upper 
portion  of  the  sternum.  At  first  the  murmur  is  quite  noisy,  but  with 
ensuing  disturbance  of  compensation  it  loses  its  intensity.  It  is 
usually  combined  with  aortic  stenosis,  becoming  the  gravest  form  of 
valvular  disease  of  childhood.  It  sometimes  causes  sudden  death,  and 
but  few  children  survive  the  age  of  puberty.  Aortic  regurgitation 
may  often  be  recognized  by  the  peculiarly  collapsing  pulse,  the  water- 
hammer  or  Corrigan's  pulse. 

Aortic  Obstruction. — This  affection  is  usually  observed  in  older 
children  in  connection  wuth  aortic  insufficiency.  The  murmur  is 
harsh,  systolic,  heard  loudest  over  the  orifice,  transmitted  to  the  right, 

*See   Fig.    21. 


540  DISEASES   OF    CHILDREN 

and  sometimes  over  the  whole  length  of  sternum,  and  the  arteries  of 
the  neck.     Hypertrophy  of  the  left  ventricle. 

Tricuspid  Regurgitation. — Except  as  a  congenital  defect,  it  most 
frequently  occurs  secondarily  to  affections  of  the  left  heart.  Auscul- 
tation reveals  a  systolic  blowing  murmur,  heard  loudest  over  the  lower 
part  of  the  sternum  (xiphoid)  and  at  the  juncture  of  the  fourth  costal 
cartilage.  Second  sound  is  weak.  Jugular  pulsation.  Hypertrophy 
and  dilatation  of  the  right  heart.  In  severe  cases  cyanosis,  and  pulsa- 
tion of  the  liver. 

Tricuspid  Ohstruction. — This  condition  is  extremely  rare  as  an  ac- 
quired heart  affection,  hence  calls  for  no  detailed  discussion.  No  par- 
ticular change  in  size  of  the  heart  is  known.  (See  ''Congenital  Heart 
Disease,"  p.  528.) 

Pulmonic  Be  gurgitation. — Insufficiency  of  the  pulmonic  valve  is 
chiefly  congenital,  rarely  acquired.  The  murmur  is  diastolic  and  lim- 
ited to  the  site  of  the  valve — at  the  juncture  of  the  left  second  costal 
cartilage  and  the  sternum.  Unlike  that  of  aortic  insufficiency  it  is  not 
transmitted  to  the  arteries  of  the  neck.    Hypertrophy  of  the  right  heart. 

Pidmonic  Ohstruction. — Principally  a  congenital  malady.  The 
murmur  is  basic,  systolic,  heard  loudest  at  the  left  second  costosternal 
junction.  It  is  associated  with  hypertrophy  of  the  right  ventricle, 
and  sometimes  with  cyanosis.     (See  "Congenital  Heart  Disease.") 

Treatment. — The  management  of  chronic  valvular  heart  disease  in 
children  is  the  same  as  in  adults.  It  differs  with  the  stages  of  the 
disease — when  compensation  is  intact,  and  when  it  ''ruptures." 

Stage  of  Compensation 

The  well-being  and  longevity  of  the  patient  stand  in  direct  ratio 
to  the  capacity  of  the  heart  to  compensate  its  insufficiency  by  second- 
ary hypertrophy  of  the  musculature  of  one  or  more  of  its  chambers. 
Hence,  the  aim  in  the  treatment  of  chronic  valvular  heart  disease 
should  be  directed  chiefly  to  the  maintenance  of  compensatory  hyper- 
trophy. Bearing  in  mind  the  facts  that  with  increasing  circulatory 
disturbance  there  is  on  the  part  of  the  heart  a  spontaneous  muscular 
development  to  overcome  its  difficulties  so  long  as  its  supply  of  nour- 
ishment is  sufficient  and  its  hypertrophic  process  is  not  interfered 
with  by  unequal  demands  upon  its  reserve  force,  as  is  apt  to  occur, 
e.  g.,  in  overexertion,  in  intercurrent  diseases  and  the  like,  we  can 
readily  formulate  a  plan  of  treatment  which  will  at  least  for  a  time, 
amply  meet  with  the  aforementioned  indication.  Parents  should  be 
given  to  understand  that  the  treatment  of  compensating  heart  dis- 
ease is  principally  prophylactic  and  hygienic  and  that  its  success  is 


DISEASES   OP    THE    CIRCULATORY    SYSTEM  541 

commensurate  with  the  degree  of  cooperation  on  the  part  of  the  pa- 
tient as  well  as  those  guiding  his  destiny,  Avhen  the  heart  is  at  its 
best.  Convalescence  from  acute  or  recurrent  heart  disease  calls  for 
very  careful  attention.  Too  earh'  attempts  at  walking  or  standing 
are  apt  to  prove  disastrous,  not  rarely  leading  to  sudden  dilatation  of 
the  heart,  perhaps  with  fatal  issue.  Beginning  with  gradual  raisings 
of  the  patient's  head  and  shoulders,  and  watching  its  effect  upon  the 
patient's  heart  action — its  strength  and  rhythm — we  may.  gradually 
allow  greater  liberties,  provided  slight  exertion  is  unattended  by 
detrimental  influences.  In  severe  cases  of  valvular  heart  disease  it 
is  usually  not  safe  to  permit  the  patient  to  be  out  and  around  in  less 
than  three  months.  A  sojourn  in  a  quiet  inland  resort  is  very  helpful 
to  recovery. 

A  heart  with  crippled  valves  demands  an  adequate  supply  of  healthy 
blood  in  the  coronary  arteries.  This  is  best  secured  by  suitable 
nutrition  and  a  rational  mode  of  living.  The  diet  must  be  appropri- 
ate to  the  age  of  the  patient,  at  all  ages  milk,  cereals  and  vegetables 
forming  the  principle  food  ingredients;  eggs,  fish,  light  meats  and 
fruit  may  be  added  off  and  on.  Liquors  and  stimulants  of  all  kinds 
should  be  avoided,  administering  instead  nutrient  tonics  such  as  malt 
and  cod  liver  oil,  with  or  without  small  quantities  of  iron  and  arsenic, 
etc. 

Special  attention  should  be  paid  to  the  action  of  the  bowels,  kidneys, 
and  skin.  Daily  cool  sponging  followed  by  gentle  massage  is  very  in- 
vigorating. Warm  clothing  is  essential,  but  unnecessary  coddling  of 
the  patient  should  be  interdicted.  Weather  permitting,  the  child' 
should  be  kept  outdoors  from  nine  in  the  morning  until  five  (later  in  the 
summer)  in  the  afternoon,  allowing  him  to  participate  in  all  such 
amusements  as  will  not  call  for  undue  exertion.  Racing,  jumping, 
football,  and  baseball  playing  and  swimming  should  be  forbidden. 
Light  athletic  exercise  is  useful,  if  it  gives  rise  to  no  undue  fatigue,  or 
disturbance  of  compensation  (see  p.  542).  Passive  exercise  in  the 
form  of  massage  is  highly  to  be  recommended.  The  question  of  how 
much  brain  work  a  patient  with  poorly  compensating  heart  disease  is  to 
be  permitted  to  do,  cannot  be  decided  offhand,  to  apply  to  all  cases.  Its 
effect  upon  the  general  health  of  the  patient  must  be  watched,  and 
changes  in  the  curriculum  promptly  made  if  headache,  insomnia,  anemia, 
debility,  excessive  nervous  irritability,  and  the  like,  make  their  appear- 
ance. 

It  is  of  very  vital  importance  to  obviate  intercurrent  diseases,  es- 
pecially infectious  diseases,  such  as  scarlatina,  articular  rheumatism, 
etc.,  which  are  apt  to  reinfect  the  endocardium  and  aggravate  the  pa- 


542  DISEASES   OF    CHILDREN 

tient's  condition.  If  such  diseases  prevail  it  is  imperative,  whenever 
practicable,  to  isolate  the  child,  or  remove  him  to  a  place  where  he  will 
be  least  exposed  to  infection.  For  fear  of  contractinf]^  contagious  dis- 
eases patients  in  good  financial  circumstances  should  be  kept  from 
visiting  public  or  private  schools  and  preferably  be  instructed  at  home. 

Particular  attention  should  be  paid  to  incipient  symptoms  of  tonsil- 
litis, "growing  pains,"  etc., — forerunners  of  rheumatism.  In  these 
conditions  the  salicylates  should  be  resorted  to  early,  to  prevent  graver 
rheumatic  manifestations.  Hypertrophied  tonsils  and  decayed  teeth 
should  receive  special  care. 

With  every  appearance  of  indisposition  the  patient  should  be  put  to 
bed,  and  kept  there  until  every  vestige  of  the  malady  has  abated. 

In  intercurrent  febrile  diseases  the  heart  demands  very  careful 
watching,  and  in  the  presence  of  any  disturbance,  immediate  treatment. 

Formal  Gymnastics — Cardiac  Cases* 

These  educational  and  hygienic  exercises,  as  the  terms  are  applied 
in  public  school  systems,  are  examples  of  the  type  of  exercise  to  be 
used  in  alternation,  so  as  to  change  the  groups  of  muscles  employed 
and  the  vigor.  The  number  of  times  and  the  vigor  with  which  the 
exercise  is  done,  will  increase  the  effort  required  of  the  heart.  The 
teacher  must  use  her  judgment  with  regard  to  the  effect  on  individual 
cases.  The  children  must  be  taught  to  discontinue  exercising  at  any 
moment  subjective  symptoms  become  marked. 

Drill  I — Duration  15  minutes. 

1.  Hands  on  shoulders — Place! 

(1)  Stretching  left  arm  upward,  right  arm  downward;   hands  on  shoulders; 

stretching  right  arm  upward,  left  arm  downward — Begin! 

2.  (1)   Point  step  forward  left,  raising  arms  forward — One! 

(2)  Point  step  sideways  left,  arms  sideways  (palms  up) — Two! 

(3)  Point  step  backward  left,  arms  upward — Three! 

(4)  Eeplacing  foot,  arms  forward,  downward — Four! 

Name  of  exercise — Point  step  forward  left,  arms  forward;   point  step  side- 
ways left,  arms  sideways;  point  step  backward  left,  arms  upward. 

3.  Hands  on  hips — Place! 

(1)  Deep  knee  bending — One! 

(2)  Stretching  knees — Two! 

This  exercise   should  be  taught  to   response  commands   and  after  it  is 
thoroughly  learned  should  be  done  in  rhythm.     Then  the  exercise  is — 
Hands  on  hips — Place! 
(1)  Deep  knee  bending — Begin! 


*The  author  is  indebted  to   Dr.   Robert   H.   Halsey   for   the  following  outline   of   the   graduate 
exercises  used  in  the  cardiac  clinics  for  children. 


DISEASES   OP    THE    CIRCULATORY    SYSTEM  543 

4.  (1)   Raising  arms  sideways — One! 

(2)  Bending  trunk  sideways  left — Two! 

(3)  Trunk  erect — Three! 

(4)  Position — Four! 

Same  right.     Alternate. 
Name — Raising  arms  sideways;   bending  trunk  sideways. 

5.  Arms  sideward.     Trunk  to  right — bend.     (Repeat  to  left.)     Trunk  raise. 

6.  (1)   Placing  left  foot  sideways,  raising  arms  sideways — One! 

(2)  Bending  trunk  forward,  bending  left  knee,  touching  left  hand  to  left  toe, 

riglit  arm  upward — Two! 

(3)  Same  as  (1)— Three! 

(4)  Position — Four! 

Sariie  riglit.     Alternate. 
Name — Placing  left  foot   sideways,   arms   sideways;    bending   trunk   forward, 
bending  left  knee,  touching  left  hand  to  left  toe  right  arm  upward. 

7.  (1)   Raising  heels  and  arms  sideways — Begin! 

8.  Hands  at  side  of  shoulders— Place! 

(1)  Stretching  arms  upward;   hands  at  sides   of   shoulders;    stretching  arms 

sideways   (palms  up) — Begin! 

Drill  II — Duration  10  minutes  additional,  mailing  25  minutes  in  all. 

1.  (1)   Placing  left  foot  sideways,  bending  arms  at  shoulder  level — One! 

(2)  Position— Two ! 

Same  right.     Alternate. 

2.  Hands  on  hips — Place! 

(1)  Bending  head  backward   (slowly) — One! 

(2)  Raising  head   (slowly) — Two! 

Repeat.  » 

3.  (1)  Deep  knee  bending,  raising  arms  sideways- — Begin! 

4.  (1)  Placing  hands  behind  neck — One! 

(2)  Bending  trunk  sideways — Two! 

(3)  Trunk  erect — Three! 

(4)  Position — Four! 

Same  right.     Alternate. 

5.  Hands  on  hips — Place! 

(1)  Raising  left  leg  forward — One! 

(2)  Lowering  left  leg  to  position  (slowly) — Two! 

Same  right.     Alternate. 

6.  Hands  on  hips — Place! 

(1)   Springing  feet  sideways — Begin! 

7.  Hands  on  hips — Place! 

(1)  Raising  left  leg  sideways  (slowly) — One! 

(2)  Position— Two! 

Same  right.     Alternate. 

8.  Hand*  on  shoulders — Place! 

(1)   Raising  heels,  stretching  arms  upward — Begin! 


544  DISEASES   OF    CHILDREN 

Drill  III — Duration  5  minutes  adclitioiud,  malcing  SO  minutes  in  all. 

1.  (1)   Clapping  hands  over  head — One! 

(2)  Eaising  left  knee,  clapping  hands  under  left  knee — Two! 

(3)  Keplacing  left  foot,  clapping  hands  over  head — Tlirec! 

(4)  Hands  on  hips — Four! 

Same  right.     Alternate. 

2.  Hands  on  hips — Place! 

(1)  Hopping  twice  on  each  foot,  starting  left — Begin! 

3.  Prone  fall  position.    Walk  forward.    Forward  jump.     Stand. 

4.  Hands  on  hips — Place! 

(1)   Raising  knees  upward,  alternately,  starting  left  in  quick  rhythm — Begin! 

5.  (1)   Eaising  heels,  arms  sideways — Begin. 

Stage  of  Failing  Compensation 

Varying  with  the  inherent  strength  of  the  patient,  the  severity  of 
the  lesion  and  the  precautionary  measures  employed,  compensation 
may  be  maintained  for  a  shorter  or  longer  time — weeks,  months,  or 
years.  However,  it  is  only  a  question  of  time  when  compensation 
ruptures.  As  previously  mentioned,  the  breakdown  may  be  only 
temporary,  (readily  yielding  to  a  few  weeks  of  rest,  careful  feeding 
and  possibly  requiring  also  a  few  doses  of  digitalis)  and  recur  on 
several  occasions.  But  sooner  or  later  the  heart  muscle  gives  way, 
the  pulse  becomes  feeble  and  irregular,  the  breathing  deep  and  diffi- 
cult, the  urine  diminished  in  quantity  and  the  general  health  of  the 
patient  greatly  impaired.  Here  rest  in  bed  is  indispensable,  but  this 
alone  is  not  sufficient  to  restore  compensation.  We  have  to  resort  to 
cardiac  stimulants  to  strengthen  the  heart  muscle  and  to  regulate  its 
beat,  and  also  to  vasodilators,  to  allow  the  blood  to  flow  in  the  arteries 
without  resistance,  with  each  ventricular  contraction.  Various  drugs 
are  being  recommended  for  this  purpose,  but  none  meets  the  indica- 
tions with  the  same  degree  of  certainty  as  digitalis,  and  the  iodides. 
In  incipient  failure  of  compensation  we  usually  begin,  for  every  two 
years  of  the  child's  age,  with  i/^  grain  of  the  sodium  iodide  and  ^4 
dram  of  the  infusion  of  digitalis,  or  one  drop  of  the  tincture,  to  be 
repeated  every  six  hours;  and  as  the  disease  advances  we  increase  the 
doses  proportionately  up  to  1  grain  of  the  iodide  and  1  dram  of  the 
infusion  of  digitalis  or  2  drops  of  the  tincture.  The  cumulative  action 
of  the  digitalis  should  be  borne  in  mind  and  its  administration  discon- 
tinued if  untoward  symptoms  arise.  In  this  event,  or  where  digitalis 
is  not  well  tolerated  by  the  stomach,  we  may  substitute  strophanthus, 
diuretin,  caffeine  sodium  benzoate  or  spartein  sulphate  instead.  The 
latter  two  remedies  have  the  advantage  that  they  may  be  safely  given 
hyperdermically  if  irritability  of  the  stomach  precludes  their  admin- 
istration by  mouth.  In  the  early  attacks  of  faihire  of  compensation 
the  benefits  obtained  from  the  simple  mode  of  treatment  just  outlined 


DISEASES   OF    THE    CIRCILATORY    SYSTEM  545 

are  often  entirely  beyond  expectation.  Sometimes  within  but  a  very 
few  days  the  urine  greatly  increases  in  quantity,  the  edema  disap- 
pears, the  dyspnea  ceases,  the  distressing  cough  abates ;  in  short, 
restoration  of  compensation  is  apparently  complete.  In  the  later 
stages  of  compensatory  failure,  however,  the  treatment  by  means  of 
rest,  good  food,  the  iodides  and  digitalis  fails  to  assert  its  magic  in- 
fluence. We  have  to  resort  to  symptomatic  medication,  especially 
with  the  view  of  relieving  suffering.  In  this  respect  the  treatment  is 
the  same  as  that  employed  in  adults,  morphine  with  or  without  atropine, 
by  mouth  or  hypodermically,  being  the  most  potent  remedy  at  our  com- 
mand. 

IJ     Strychninae  Sulph.  gr.  %  0.008 

Natrii  lodidi  gr.  xvj  1.000 

Inf.  Digitalis  fol.  3j  30.000 

Syr.  Althc*  q.  s.  ad  5  ij  60.000 

M. 

S. — One  teaspoonful  t.  i.  d.,  for  a  child  four 
years  old.     (Alterative  heart  tonic.) 


Syr.  Ferri  lodidi 

3  iij          12.0 

Syr.  Aurantii 

q.  s.  ad  3  ij           60.0 

M. 

S. — One  teaspoonful 

every  four  hours,  for  a 

child    four    years    old. 

(Between    "heart    at- 

tacks.") 

K     Liq.  Ferri  et  Ammonii  Acetatis 

Inf.  Digitalis  fol.  aa  3  j     I     30.0 

M. 

S. — One  teaspoonful  every  four  hours,  for  a 
child  four  years  old.     (When  dropsy  is  present.) 

1}     Tr.  Digitalis 

Tr.  Strophanthi  aa  3  ij      I     8.0 

M. 

S. — Five  to  ten  drops  every  four  hours,  for  a 
child  four  years  old.  (In  marked  heart  dilata- 
tion with  irregularity.) 


Stryehninae  Sulph.                              gr.  % 

■    0.012 

Caffeinae  Natrii  Benzoatis              gr.  xij 

0.800 

Aq.  Destil.                                             3  ij 

8.000 

M. 

S. — Ten  drops  hypodcrmically,  p.   r.  n 

,  for  a 

child  four  years  old.      (Quick  stimulant.^ 

A  light  diet  is  essential.  Skimmed  milk  (Karell's  diet  for  heart 
disease),  3  to  6  ounces  every  four  hours,  is  often  very  beneficial.  This 
diet  may  be  strengthened  by  the  addition  of  cereals  and  lactose. 


CHAPTER  X 
DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS 

DISEASES  OF  THE  BLOOD 

Affections  of  the  blood  are  of  very  common  occurrence  in  children, 
especially  in  infancy  and  in  those  approaching  puberty.  At  these  pe- 
riods of  life,  owing  to  the  rapid  bodily  development,  the  blood-form- 
ing organs  are  taxed  to  their  greatest  capacity,  and,  hence,  are  very 
apt  to  suffer  on  slight  provocation.  The  anemias  of  children  are 
usually  secondary  in  nature,  only  exceptionally  primary.  With  the 
present  inadequate  state  of  our  knowledge,  however,  no  sharp  line 
of  demarcation  can  as  yet  be  drawn  between  the  various  types  of 
blood  disease.  Only  too  often  do  we  find  the  clinical  and  histologic 
aspects  of  simple  secondary  anemia  merging  into  that  of  splenic 
anemia,  and  that,  of  the  latter  disease  into  the  one  of  leukemia.  The 
same  is  true  of  lymphatic  leukemia,  chloroma,  and  lymphosarcoma. 
For  the  reasons  just  stated,  therefore,  no  attempt  will  here  be  made 
to  offer  an  iron-clad  classification  of  the  diseases  in  question. 

In  studying  blood  disease  it  is  well  to  bear  in  mind  that  the  con- 
stituents of  the  normal  blood  vary  within  more  or  less  wide  limits, 
and  that  slight  ailments  are  prone  to  produce  marked  disproportion 
between  the  number  of  red  and  white  blood  corpuscles. 

At  birth  the  number  of  red  cells  is  about  6,000,000,  and  of  white  cells, 
between  20,000  to  30,000  per  cubic  millimeter.  The  hemoglobin  is 
very  high,  about  110  per  cent  and  the  specific  gravity  1,066.  After 
the  second  week  the  red  cells  fall  to  5,000,000,  and  the  white  cells  to 
about  15,000,  the  hemoglobin  to  100  per  cent,  and  the  specific  gravity 
to  1,050.  The  red  cells  are  fewer  in  number  in  the  female  than  in  the 
male.  The  perceniage  of  the  different  leucocytes  in  infants  presents 
the  following  variations:  Polymorphonuclear  neutrophiles,  28  to  50; 
polymorphonuclear  eosinophiles,  i/^  to  10;  lymphocytes,  50  to  70,  and 
large  mononuclears,  6  to  14.  The  adult  proportion  is  usually  reached 
by  the  time  the  child  is  eight  years  old.  Then  the  number  of  poly- 
morphonuclears rises  to  65  or  75  per  cent  and  that  of  the  lymphocytes 
falls  to  20  or  30,  and  of  the  mononuclears,  to  1  to  4.  Normally,  coagu- 
lation of  the  blood  usually  occurs  within  from  two  to  five  minutes. 

546 


DISEASES    OF    THE    BLOOD    AND   DUCTLESS   GLANDS 


547 


differp:ntial  blood  counts  in  normal  children 

(After  Scliloss) 


Age 

POLY- 

MOKPIIO- 
NT'CLEARS 

LVMIMIO- 

CYTK.S 

Large 
Mono- 
nuclears 

Eosixo- 

I'lIILES 

Baso- 

PHILES 

montlis 
6-12 

j    Maximum 

35.9 

58.5 

12.2 

4.5 

0.8 

I    Minimviiii 

2-L6 

50.5 

7.3 

0.0 

0.1 

[  Average 

30.4 

55.9 

9.6 

2.6 

0.4 

f   Maximum 

30.7 

58.8 

11.7 

5.0 

0.5 

1-2  yrs. 

1    MinimuTii 

27.5 

45.3 

6.7 

1.6 

0.0 

[   Average 

36.3 

51.2 

8.5 

3.2 

0.2 

f   Maximum 

44.3 

55.0 

11.3 

0.5 

1.2 

2-3  yrs. 

\    Minimum 

33.2 

4.3.5 

5.0 

3.1 

0.0 

[  Average 

38.7 

49.9 

8.2 

6.0 

0.4 

r   ^raximum 

54.1 

47.6 

16.2 

4.2 

0.9 

3-4  yrs. 

<    Minimum 

36.2 

32.2 

6.0 

1.5 

0.0 

[  Average 

44.7 

39.1 

11.2 

2.8 

0.5 

f  Maximum 

51.7 

49.5 

6.7 

4.0 

0.6 

4-5  yrs 

<  Minimum 

42.2 

38.4 

3.4 

1.6 

0.3 

I.  Average 

48.'5 

42.1 

6.0 

2.6 

0.3 

f  Maximum 

61.8 

36.7 

16.0 

4.7 

1.0 

5-6  yrs. 

<    Minimum 

52.6 

21.2 

6.5 

0.7 

0.3 

[  Average 

56.5 

29.9 

10.0 

2.5 

0.6 

r  IVIaximum 

61.3 

.34.1 

15.7 

4.7 

0.6 

6-7  yrs. 

<    Minimum 

52.3 

24.5 

8.1 

0.1 

0.0 

[  Average 

56.0 

30.4 

10.8 

2.2 

0.2 

r  Maximum 

72.0 

39.1 

15.2 

3.5 

0.2 

7-8  yrs. 

<    Minimum 

45.2 

21.1 

6.7 

0.0 

0.0 

1^  Average 

54.4 

32.5 

11.6 

6.1 

0.6 

Anemia  Simplex,  Chlorosis 

(Green  Sickness) 

Both  of  these  conditions  present  identical  pathologic  changes  in  the 
blood — reduction  in  the  number  of  red  cells,  decrease  of  hemoglobin, 
without  marked  changes  in  the  cells  themselves — but  differ  some- 
what in  the  etiology  and  course.  Thus,  while  chlorosis  is  ordinarily 
encountered  in  girls  at  puberty,  and  almost  invariably  ends  in  re- 
covery without  any  grave  alterations  in  the  general  health,  anemia 
is  a  disease  of  younger  children,  and  if  occurring  in  infants  very  fre- 
quently forms  the  forerunner  of  that  type  of  blood  disease  which  is 
generally  described  as  pseudoleukemia  infantum  {q.  v.).  Anemia  in 
the  newborn  may  be  congenital  (disease  of  the  mother,  especially 
syphilis,  tuberculosis,  and  malaria)  or  acquired  (hemorrhage;  sepsis). 

Anemia  as  well  as  chlorosis  is  manifested  by  pallor  of  the  face 
(waxy  or  green  complexion)    and  mucous  membranes,  headache,   dys- 


548  DISEASES   OF    CHILDREN 

peptic  symptoms,  undue  fatigue  after  slight  exertion,  attacks  of  pal- 
pitation of  the  heart  and  of  dyspnea,  general  debility  and  excessive 
irritability  of  the  nerve  system.  In  young  infants  the  ears  usually 
show  a  peculiar  waxy  transparency.  Auscultation  often  reveals  hemic 
murmurs  along  the  large  veins  of  the  neck  and  at  the  base  of  the 
heart,  which  differ  from,  organic  murmurs  by  their  inconstancy  and 
frequent  change  in  their  intensity  and  location. 

In  addition  to  the  aforementioned  manifestations,  chlorosis  in  ma- 
ture girls  is  very  prone  to  give  rise  to  amenorrhea,  dysmenorrhea,  and 
less  frequently  to  menorrhagia  with  consequent  aggravation  of  the 
original  condition;  severe  chlorosis  is  apt  to  be  complicated  by  venous 
thrombosis,  especially  in  the  lower  extremities  and  the  brain  sinuses, 
and  occasionally  by  secondary  gangrene  and  embolism.  Of  course 
such  occurrences  are  very  exceptional.  The  very  great  majority  of 
cases  of  chlorosis,  as  already  stated,  improve  rapidly  and  fully,  al- 
though relapses  are  not  uncommon. 

The  management  of  anemia  and  chlorosis  to  a  great  extent  varies 
with  the  numerous  etiologic  factors.  The  general  health  should  be 
improved  by  suitable  nutritious  diet,  plenty  of  outdoor  air,  in  older  chil- 
dren cold  shower  baths  with  gentle  massage,  ample  sleep,  and  avoidance 
of  undue  excitement  and  physical  and  mental  overexertion.  Dj'spepsia, 
habitual  constipation,  diarrhea,  loss  of  blood  (epistaxis,  etc.),  hered- 
itary syphilis,  malaria,  tuberculosis,  heart  and  kidney  affections,  and 
all  other  diseases  as  are  apt  to  undermine  the  system  should  receive 
prompt  and  continuous  attention.  Where  circulatory  disturbances 
are  very  pronounced,  rest  in  bed  is  indispensable.  Medicinally,  iron 
and  arsenic  are  the  remedies  of  choice.-  The  following  combination 
acts  splendidly : 

IJ     Liqiioris  Arsenici  Chloridi                    3  i  4.00 

Tr.  Ferri  Chloridi                                 3  iii  12.00 

Syr.  Aurantii                            q.  s.  ad  5  iii  90.00 
M. 

S. — One  tcaspoonful  every  three  hours,  for  a 
child  six  years  old. 

In  older  children  to  avoid  destruction  of  the  teeth,  the  iron  and 
arsenic,  without  syrup,  may  be  prescribed  with  instructions  to  be 
taken  in  capsule  form,  each  dose  being  prepared  before  taking  it  in 
accordance  with  the  directions  given  on  page  104. 

Digestives  and  tonics  (cod  liver  oil)  will  be  found  to  act  as  useful 
adjuvants.     Change  of  air,  preferably  to  mountainous  regions. 


DISEASES   OF    THE    BLOOD    AND   DUCTLESS   GLANDS 


549 


Pseudoleukemia  Infantum,  Splenica 
(von  Jaksch's  or  Splenic  Anemia) 

This  condition  was  first  described  by  von  Jaksch  in  1889  as  a 
clinical  entity.  It  is  observed  in  infants  from  six  to  twenty-four 
months  of  age,  corresponding  with  the  age  w^hen  rachitis  and  gastro- 
intestinal affections  are  most  prevalent.  Hence  the  reason  why  some 
authors  look  upon  it  as  a  secondary  rather  than  a  primary  anemia. 

The  chief  alterations  in  the  blood  are  reduction  of  red  cells  and 
hemoglobin  (sometimes  as  low  as  20  per  cent),  the  presence  of  many 


Fig.  15G. — Splenomegaly  in  association  with  von  Jaksch  anemia. 


nucleated  red  corpuscles,  and  a  considerable  increase  in  the  number 
of  leucocytes,  mostly  of  the  mononuclear  type.  This  blood  picture 
essentially  corresponds  to  that  of  ordinary  secondary  anemia.  In 
pseudoleukemia  infantum,  however,  there  is  an  enormous  enlarge- 
ment of  the  spleen  and  usually  also  slight  enlargement  of  the  liver 
and  lymphatic  glands. 


550  DISEASES    OF    CHILDREN 

The  general  sj^mptoms  differ  but  little  from  those  observed  in 
severe  anemia.  The  same  applies  to  the  treatment.  The  SA'rup  of  the 
iodide  of  iron  with  the  syrup  of  the  hypophosphites  and  red  bone  mar- 
row seem  to  exert  a  specific  action  in  the  majority  of  cases. 

Pseudoleukemia  Lymphatica 
(Hodgkin's  Disease,  Adenie,  Lymphadenoma) 

In  contrast  to  splenic  anemia  this  disease  is  not  peculiar  to  infancy 
and  is  characterized  by  multiple  hyperplasia  of  the  lymph  glands  with 
progressive  anemia.  The  cervical  glands  are  most  commonly  and 
severely  attacked,  but  the  lymphoid  tissue  of  the  entire  body  is  more 
or  less  involved.  It  closely  resembles  tuberculous  adenitis,  except 
that  it  is  much  more  uncommon  than  tuberculosis  and  that  in  the 
latter  condition  the  glands  show  a  greater  tendency  to  caseation  and 
suppuration.  In  doubtful  cases  the  tuberculin  test  may  prove  de- 
cisive in  the  diagnosis. 

The  changes  in  the  blood  and  the  clinical  manifestations  are  identi- 
cal with  those  observed  in  severe  anemia.  Occasionally,  there  are  local 
pressure  symptoms,  such  as  pain,  edema,  cough  and  dj'spnea. 

Under  suitable  treatment  (see  "Anemia,"  p.  548)  recovery  or  at 
least  arrest  of  the  disease  is  possible.  Of  late  arsenic  in  the  form  of 
salvarsan  has  been  employed  with  considerable  success.  X-ray  therapy 
also  is  worth  trying  and  some  clinicians  advise  surgical  intervention. 
Intractable  cases  often  terminate  in  leukemia. 

Leukemia 

(Leucocythemia) 

As  the  term  indicates,  leukemia  is  characterized  principally  by  an 
abnormal  increase  in  the  number  of  leucocytes  (sometimes  reaching 
as  high  as  a  million),  and  by  the  presence  of  unusual  types  of  these 
cells,  i.  e.,  "Markzellen"  (myelocytes),  "Mastzellen"  (nutritive  cells), 
and  giant  basophiles.  From  a  pathologic  point  of  view  it  is  custom- 
ary to  distinguish  two  forms  of  leukemia:  (1)  Lymphatic  leukemia, 
in  which  the  lymphatic  glands  are  chiefly  involved  (hyperplasia)  ; 
and  (2)  splenomedullary  or  myelogenic  form,  in  which  the  spleen 
(greatly  increased  in  size)  and  the  bone  marrow  (hyperplasia)  are 
the  principal  seats  of  the  lesion.  Mixed  forms  also  are  encountered. 
The  principal  difference  between  the  two  forms  of  leukemia  are  the 
preponderance  of  lymphocytes  in  lymphatic,  and  myelocytes  in  splenic 
leukemia.    The  red  cells  and  hemoglobin  are  reduced  in  both  varieties. 


DISEASES   OF    THE    BLOOD   AND   Dtf^TLtSS  GfcANDS  '  '  551 

-.  rj  •/  ■^   :   ■'   f  ,r    ^  ,■  r        r 

The  clinical  manifestations  are  essentially  identical  with  those  of 
pernicious  anemia  (g.  t'.),  plus  enlargement  of  the  lymphatic  glands, 
(of  the  neck,  axilla  and  inguinal  regions),  the  spleen  and  liver.  There 
is  a  marked  tendency  to  hemorrhage  in  the  skin  and  mucous  mem- 
branes ;  progressive  anemia ;  recurrent  fever ;  edema.  The  disease  may 
run  a  very  acute  course  (acute  leukemia),  and  end  fatally  within  a 
week  or  two,  or  proceed  a  slower  course  (chronic  leukemia),  and 
lead  to  a  fatal  issue  after  a  few  months. 

As  the  nature  of  leukemia  is  entirely  obscure,  little  else  can  be 
done  but  treat  it  symptomatically.    (See  Anemia  and  Pseudoleukemia.) 

Pernicious  Anemia 

This  form  of  anemia  is  characterized  by  great  diminution  in  the 
number  of  red  cells  (2,000,000  to  1,000,000  per  c.  mm.)  ;  reduction  in 
the  total  quantity  of  hemoglobin  with  a  comparative  increase  of  the 
hemoglobin  in  the  red  cells;  increase  in  the  size  of  the  red  cells  with 
predominance  of  megaloblasts ;  loss  of  cohesive  quality  of  the  red 
cells  (their  failure  to  form  rouleaux),  and,  finally,  absence  of  distinct 
changes  (or  slight  reduction)  in  the  number  of  the  leucocytes. 

This  blood  affection  is  very  rarely  met  with  in  children.  As  in 
adults,  it  may  occur  secondarily  to  protracted  simple  anemia  or  in 
consequence  of  abstraction  of  blood  by  intestinal  parasites,  e.  g., 
bothriocephalus  latus;  uncinaria  (g.  i^.). 

In  the  beginning  the  symptoms  resemble  those  of  severe  simple  anemia 
{q.  v.),  but  at  a  later  stage  of  the  disease  the  condition  is  greatly  ag- 
gravated by  supervening  hemorrhages  from  the  mucous  membranes, 
cutaneous  ecchymoses,  and  general  dropsy.  In  such  cases  death  in- 
variably occurs  w^ithin  a  few  months. 

Pernicious  anemia  occasionally  gives  rise  to  lesions  in  the  spinal 
cord  with  corresponding  symptoms  (paralysis  of  the  extremities,  etc.). 

Postmortem  examination  usually  reveals  fatty  degeneration  of  the 
internal  organs. 

The  Treatment. — The  treatment  is  the  same  as  in  severe  anemia. 
(See  p.  548.)  In  addition,  removal  of  the  intestinal  parasites,  if 
present,  and  transfusion. 

A.  D.  Espine  (Rev.  Med.  de  la  Suise  Romande,  August,  1918)  re- 
ports the  recovery  of  two  young  infants  treated  by  a  special  serum. 
The  serum  was  obtained  by  venesection  of  animals  at  the  height  of 
the  regeneration  of  blood  following  a  previous  extensive  withdrawal 
of  blood.  'This  ''hematopoietic  serum"  was  injected  subcutaneously 
daily  in  doses  of  from  S  c.c.  to  10  c.c.    The  improvement  was  gradual. 


J  '  r 


1  \-\  t5>5?o  "^^ ":'  c  0    n  C   3  i9  3  JclifejIsES  of  children 

Hemorrhea  Congenita 

(Hemophilia) 

Hemophilia  is  an  inherited,  congenital  tendency  to  posttraumatic 
or  spontaneous,  profuse,  often  uncontrollable,  hemorrhage.  It  affects 
the  male  much  more  frequently  than  the  female,  though  the  disease 
is  transmitted  through  the  female.  The  disease  becomes  less  marked 
with  advancing  age. 

According  to  Haliburton,  the  process  of  blood  coagulation  is  as 
follows: 

Blood  platelets   and  leuco-  The  blood  cells  and  tissues  of 

cytes   give   thrombogen  the   body   give   thrombokinase 


Blood    plasma   furnishes  In  the  presence  of  calcium 

a  protein  fibrinogen  salts  thrombokinase  activates 

I  thrombogen  into  an  enzyme 


Thrombin  acts  on  fibrinogen  to  give 

Fibrin 

Minot  and  Lee  maintain  that  the  active  coagulating  principle  of 
the  tissue  juice  is  derived  in  part,  if  not  wholly,  from  the  blood 
platelets  and  that  in  hemophilia  there  is  an  hereditary  defect  in  the 
platelets,  though  normal  in  number.  In  addition  to  this  there  is  also 
a  congenital  permeability  and  friability  of  the  blood  vessels. 

While,  as  previously  alluded  to,  the  hemorrhage  may  start  spon- 
taneously, in  the  great  majority  of  cases  it  follows  some  trivial  injury. 
A  scratch  or  the  prick  of  a  pin  or  slight  abrasion  of  the  body  surface, 
vaccination,  snipping  of  the  frenum  linguae,  circumcision,  extraction  of  a 
tooth,  opening  of  abscesses,  etc.,  are  followed  by  severe,  often  by  un- 
controllable, hemorrhage.  Any  undue  exertion  of  a  muscle  or  a  group 
of  muscles  (e.  g.,  jumping  off  a  chair,  sudden  twisting  of  an  arm),  a 
bump  or  a  blow,  etc.,  often  gives  rise  to  a  profuse  extravasation  of 
blood  into  the  skin  or  joints.  Forcible  blowing  of  the  nose  may  be 
followed  by  an  exsanguinating  nosebleed,  and  in  a  case  under  obser- 
vation sneezing  produced  an  enormous  hemorrhage  from  the  nose  and 
ear  (rupture  of  the  drum!)  which  nearly  ended  fatally.  In  girls 
hemorrhages  may  occur  from  the  vagina  (often  mistaken  for  men- 
struatio  precox)  long  before  the  age  of  puberty;  and  with  establish- 
ment of  menstrual  function,  the  bleeding  may  be  so  profuse  as  to 


DISEASES   OF    THE    BLOOD   AND    DUCTLESS    GLANDS  553 

leave  the  patient  monthly  in  a  state  of  collapse.  Hematemesis,  hemor- 
rhage from  the  bowels  and  hematuria  are  less  common,  and  bleeding 
into  the  serous  cavities  (peritoneal,  pleural  and  pericardial)  and  the 
brain  are  still  less  frequent.  Hemophilia  in  the  newborn  may  be 
manifested  during  or  immediately  after  birth  by  severe  hemorrhages 
occurring  from  abrasions  and  contusions  sustained  during  delivery, 
or  after  cutting  the  umbilical  cord.  These  hemorrhages  are  not  to 
be  mistaken  for  hemorrhage  in  the  newborn  complicating  sepsis  (see 
p.  229),  or  the  so-called  transitory  hemophilia  which  is  manifested  by 
idiopatliic  umbilical  hemorrhage  (see  p.  222),  or  fearful,  sometimes 
fatal  ])leeding  following  ritual  circumcision.  In  this  form  of  hemo- 
philia the  tendency  to  hemorrhage  is  greatest  between  the  seventh 
and  fourteenth  days  of  life,  gradually  lessening  in  intensity  until  the 
infant  reaches  the  age  of  two  or  three  months,  when  it  disappears  en- 
tirely. The  differential  points  of  diagnosis  between  hemorrhea  con- 
genita and  hemorrhea  acquisita  will  be  spoken  of  in  the  discussion  of 
the  latter  affection. 

Treatment. — Little  of  a  permanent  cure  can  be  expected  from  treat- 
ment, except  in  mild  forms  of  hemophilia  ("partial  bleeders").  In 
these  cases  gelatine  as  a  food,  and  calcium  chloride,  in  from  2  grain 
to  5  grain  doses,  twice  daily,  to  be  continued  for  months  or  years, 
will  prove  of  some  benefit.  Thyroid  gland  substance,  in  small  doses, 
continued  for  weeks  at  a  time,  is  deserving  of  trial.  For  the  immedi- 
ate arrest  of  the  hemorrhage  we  must  resort  to  transfusion  or  injec- 
tion of  whole  blood  (2  or  3  ounces  two  or  three  times  a  day)  into  the 
gluteal  region.  In  slight  local  hemorrhage  good  results  are  often  ob- 
tained from  the  topical  application  of  thrombokinase  and  thrombo- 
plastin. 

We  should  guard  against  injuries  and  operative  interference  (gela- 
tin feeding  before  operation  is  helpful)  of  all  kinds. 

Bleeders,  especially  females,  should  not  marry; 

Hemorrhea  Acquisita 

(Purpura  Simplex,  Purpura  Hemorrhagica  s.  Morbus 
Maculosus,  Purpura  Fulminans) 

Purpura  is  an  acquired  affection  of  the  blood  or  its  vessels  char- 
acterized by  hemorrhage  into  the  skin,  mucous  membranes  and  other 
tissues,  and  hy  more  or  less  marked  constitutional  disturbance. 

The  etiology  of  the  disease  is  still  obscure,  but  is  probably  a  toxemia 
or  a  specific  microorganism  which  invades  the  blood  and  is  essentially 
identical  with  septic  hemorrhage  seen  in  the  newborn  (q.  v.). 


554  DISEASES   OF    CHILDREN 

Purpura  is  most  frequently  observed  in  children  (male  and  female) 
over  five  years  of  age,  and  more  rarely  in  younger  ones.  It  occurs 
either  as  a  primary  affection,  or  in  connection  with  acute  infectious 
diseases,  such  as  scarlatina,  measles,  typhoid,  influenza,  etc.,  and 
shows  a  predilection  for  poorly  nourished,  anemic  and  rachitic  chil- 
dren living  in  dark,  damp  dwellings,  with  bad  hygienic  surroundings. 

Consonant  with  the  degree  of  severity  of  the  affection,  it  is  cus- 
tomary to  distinguish  the  following  forms  of  purpura: 

1.  Purpura  Simplex.— The  hemorrhage  is  confined  to  the  skin  only, 
and  appears  as  pinhead-  to  lentil-sized  spots  at  first  upon  the  lower 
extremities,  but  later  also  on  the  other  portions  of  the  body.  Aside 
from  occasional  prodromata  consisting  of  gastroenteric  disturbance 
of  brief  duration,  it  is  free  from  constitutional  manifestations.  The 
majority  of  these  cases  pursue  a  favorable  course.  The  petechia 
either  subside  entirely  within  from  one  week  to  one  month,  or  return 
at  short  or  long  intervals,  in  which  latter  event  transition  into  a 
severe  type  of  the  disease  is  not  uncommon. 

2.  Purpura  s.  Peliosis  Rheiunatica. — (See  p.  422.) 

3.  Purpura  Hemorrhagica  (Morbus  Maculosus  Werlhofii). — This 
form  of  purpura  is  manifested  b}^  hemorrhages  in  the  skin  as  well  as 
in  the  mucous  membranes.  Its  onset  is  either  sudden  or  preceded  by 
slight  prodromata  or  purpura  simplex.  The  skin  petechige  may  vary 
in  size  from  a  lentil  to  the  palm  of  a  hand,  and  do  not  disappear  on 
pressure.  They  usually  spread  rapidly  over  the  entire  body.  The 
hemorrhages  into  the  mucous  membranes  are  rarely  very  profuse. 
As  a  rule,  there  are  only  ecchymoses  upon  the  mucous  membranes  of 
the  nose,  gums,  and  pharynx,  but  in  severe  cases  the  hemorrhagic 
tendency  may  extend  to  almost  every  structure  and  organ  of  the  body, 
so  that  the  patient  bleeds  from  the  nose,  mouth,  ears,  retina  and 
choroid,  throat,  lungs,  stomach,  bowels,  kidneys,  genitalia,  etc.,  and 
sometimes  even  into  the  brain  and  cord.  Under  these  conditions  there 
are  well-marked  constitutional  symptoms  (prostration,  headache  and 
articular  pain,  cerebral  symptoms  as  a  result  of  the  anemia  or  menin- 
geal hemorrhage,  colic  and  tenesmus,  etc),  but  in  mild  cases  the  pa- 
tient may  appear  perfectly  well.  The  course  of  the  disease,  therefore, 
varies  Avith  the  seat  and  amount  of  the  bleeding.  An  attack  of  pur- 
pura hemorrhagica  of  medium  severity  usually  lasts  from  ten  to 
fourteen  days.  After  about  a  week  the  cutaneous  ecchymoses  begin  to 
change  from  the  original  red  to  bluish,  yellow,  greenish  and  brown, 
and  disappear  entirely  within  another  week.  The  hemorrhages  from 
the  mucous  membranes  and  viscera  also  gradually  cease,  the  general 
condition  of  the  patient  improves,  and  recovery  ensues,  apparently 


DISEASES    OF    THE    BLOOD    AND    DUCTLESS    GLANDS  555 

without  any  serious  consequences.  On  the  other  hand,  in  a  great 
many  cases,  the  course  of  the  first  attack  may  be  protracted  for  -weeks 
and  months  by  frequent  recurrence  of  the  bleeding,  and  lead  to  pro- 
found anemia  and  death,  or  establish  a  tendency  to  relapses,  which 
ma}'  manifest  themselves  on  slight  provocation. 

The  blood  changes  vary  with  the  degree  of  the  hemorrhage.  We 
usually  find  the  usual  manifestations  of  profound  anemia. 

4.  Purpura  Fulminans  (Henoch). — This  type  of  purpura  is  essen- 
tially identical  with  the  foi'mer  variety,  except  that  its  course  is  ex- 
tremely rapid  and  violent,  with  severe  constitutional  symptoms,  such 
as  chills,  vomiting,  intense  abdominal  pain  and  intestinal  hemorrhage, 
hyperpyrexia,  cerebral  symptoms,  and  collapse.  It  is  invariably  fatal, 
death  taking  place  with  symptoms  of  cardiac  paralysis,  within  from 
one  to  four  days.    Postmortem  findings  resemble  those  of  severe  anemia. 

Purpura  may  occasionally  be  complicated  by  gangrene  of  the  skin, 
subcutaneous  tissue  or  mucous  membranes,  rendering  the  prognosis 
very  much  worse. 

In  the  early  stage  of  the  disease  hemorrhea  acquista  may  be  mis- 
taken for  hemorrhea  congenita,  infantile  scurvy,  and  exanthemata 
(scarlatina,  morbilli  diphtheria,  variola,  typhoid,  etc.)  with  hemor- 
rhagic symptoms. 

Differential  Diagnosis 

Hemorrhea  congenita  presents  a  history  of  an  hereditary  tend- 
ency, most  frequently  follows  some  local  injury,  and  if  it  occurs 
spontaneously,  it  very  rarely  involves  several  portions  of  the  body 
simultaneously. 

Infantile  scurvy  is  an  affection  principally  of  early  infancy  and  as- 
sociated with  malnutrition.  The  hemorrhage  is  also  deepseated  (sub- 
periosteal). 

Exanthemata  have  pathognomonic  symptoms  of  their  own  (high  fever) 
which  are  wanting  in  purpura.  The  concurrence  of  the  former  with  the 
latter,  however,  should  not  be  lost  sight  of. 

Septic  purpura  can  readily  be  recognized  by  the  other  septic  symptoms. 

Treatment, — The  treatment  of  purpura  is  very  unsatisfactory. 
Mild  cases  usually  recover  spontaneously,  and  grave  ones  may  go  from 
bad  to  worse  even  under  the  best  mode  of  treatment.  In  bad  cases 
transfusion  is  indicated.  Absolute  rest  in  bed,  nutritious  diet,  plenty 
of  fresh  air,  iron  and  arsenic,  and  the  administration  of  fresh  fruit 
juice  will  enhance  the  arrest  of  milder  forms  of  the  disease. 

Local  hemorrhage  should  be  treated  in  accordance  with  the  rules 
laid  down  for  the  management  of  bleeding  from  other  causes  (com- 


556  DISEASES   OP    CHILDREN 

pression,   ice   bags,   styptics,   etc).     After   cessation   of   the   bleeding 
tonics  are  useful.     Stimulants,  in  collapse. 

Morbus  Addisonii 
(Bronzed  Skin) 

The  pathogenesis  of  this  affection  is  as  yet  awaiting  correct  inter- 
pretation. While  in  the  majority  of  cases  postmortem  examination 
reveals  disease  of  the  suprarenals  (caseation  or  calcification),  cases  of 
Addison's  disease  are  also  on  record  which  failed  to  show  distinct 
pathologic  change  in  these  glands.  The  disease  usually  attacks  chil- 
dren over  ten  years  of  age,  and,  exceptionally,  younger  ones.  It  is 
manifested  by  progressive  emaciation,  dyspepsia,  uncontrollable  diar- 
rhea, anemia,  and  bronze-like  discoloration  of  the  skin  and  mucous 
membranes.  The  discoloration  begins  at  the  breast  nipples,  axillary 
regions,  hands  and  face,  and  gradually  affects  the  entire  body  (ex- 
cept the  conjunctivae  and  nails).  The  patients  succumb  within  a  few 
months  or  years  to  exhaustion  and  paralysis  of  the  heart. 

Hematinics,  roborants,  and  the  thymus,  suprarenal,  parathyroid 
and  pituitary  extracts,  are  deserving  of  trial. 

Diseases  of  the  Spleen 

Spleen  affections  are  manifested  i)rincipally  by  enlargement  of  the 
organ,  demonstrable  by  palpation  and  percussion. 

Movable  Spleen 

(Wandering  Spleen,  Lien  Mobilis) 

This  condition  is  important  chiefly  from  a  diagnostic  point  of  vicAV, 
as  it  is  apt  to  be  mistaken  for  splenic  enlargement.  It  differs  from 
the  latter  by  the  absence  of  constitutional  symptoms  and  by  the  softer 
consistence  of  the  spleen.  It  is  usually  associated  with  general  atony 
of  the^  entire  musculature,  especially  of  the  abdominal  wall,  and  in 
older  children  not  rarely  with  enteroptosis,  floating  liver  and  kidneys. 
Subjective  symptoms  may  be  absent.  Older  children  may  complain 
of  a  feeling  of  weight  or  pain  in  the  left  side,  colic,  and  nausea. 

Mild  cases  frequently  obtain  permanent  relief  from  the  use  of  an 
abdominal  binder  and  general  tonic  treatment  (massage,  cod  liver 
oil,  arsenic).  In  very  pronounced  cases  surgical  interference  is  in- 
dicated. 


DISEASES    OF    THE    BI.OOD    AXD   DUCTLESS    GLAXDS  557 

Acute  Splenitis 

(Splenic  Congestion) 

An  acute  splenic  enlargement  may  be  caused  Ijy  malaria,  typhoid, 
recurrent  fever  and  miliary  tuberculosis,  more  rarely  by  influenza, 
rotheln,  scarlet  fever,  tuberculous  meningitis,  mumps,  erysipelas  and 
angina.  Very  rapid  and  intense  enlargement  of  the  spleen  may  occa- 
sionally be  followed  by  rupture  of  the  spleen,  hemorrhage  in  the  ab- 
dominal cavity  and  death. 

In  the  majority  of  instances  the  splenitis  subsides  spontaneously 
with  the  underlying  cause.  If  the  disease  is  due  to  direct  infection 
by  pyogenic  microorganisms,  trauma  (with  open  wound)  or  metasta- 
sis, it  may  end  in  suppuration  (splenic  abscess).  Occasionallj^  the 
inflammation  extends  to  the  surrounding  tissues,  especially  to  the 
capsule  of  the  organ,  perisplenitis,  and  gives  rise  to  inflammatory  ad- 
hesions to  neighboring  structures  (diaphragm,  colon,  or  fundus  ven- 
triculi). 

Chronic  Inflammation  of  the  Spleen 

(Chronic  Hypertrophy^  Splenomegaly) 

Occasionally  chronic  enlargement  of  the  spleen  is  the  result  of 
acute  splenitis.  Most  frequently,  however,  it  develops  insidiously  in 
connection  with  chronic  malaria,  syphilis,  tuberculosis,  rachitis,  leu- 
kemia, pseudoleukemia  and  amyloid  degeneration. 

The  symptoms  vary  with  the  original  cause  and  the  degree  of  pres- 
sure exerted  by  the  spleen  upon  the  neighboring  structures.  No  at- 
tempt will  therefore  be  made  to  go  into  a  detailed  description  of  the 
symptomatology.  Mention  may  here  be  made  of  the  fact  that  in  the 
so-called  "idiopathic"  splenomegaly  the  patient  may  appear  entirely 
free  from  constitutional  manifestation. 

Treatment. — This  is  symptomatic.  If  the  spleen  alone  is  involved 
and  gives  rise  to  grave  pressure  symptoms,  splenectomy  may  have  to 
be  resorted  to. 

Banti's  Disease 

This  disease  is  infrequently  observed  in  children.  In  some  cases  a 
history  of  syphilis  is  obtainable.  It  is  characterized  by  spleno- 
megaly, anemia,  ascites,  cirrhosis  of  the  liver,  and  hemorrhages. 
Postmortem  examination  usually  discloses  a  fibrosis  of  the  retic- 
ulum of  the  spleen,  liver  and  the  portal  vein.  The  bone  marrow 
and  lymph  nodes  are  normal.  Early  splenectomy  is  said  to  cure  the 
affection.  The  diagnosis  can  be  made  only  by  exclusion  of  similar 
spleen  and  liver  diseases. 


558 


DISEASES   OF   CHILDREN 

Primary  Family  Splenomegaly  (Gaucher) 


This  peculiar,  appareutlj-  congenital,  enlarg^ement  of  tlie  spleen  is 
occasionally  (only  4  cases  came  under  my  personal  observation)  en- 
countered in  two  or  more  members  of  the  same  family.  Although  ac- 
curately described  by  P.  C.  E,  Gaucher  in  1882  (De  1'  epithelioma 
primitif,  etc.,  etc.)  and  carefully  studied  since  then  in  the  living  and 


Fig.  157.  Fig.  158. 

Figs.  157  and  158. — Primary  family  splciiohcpatomcgaly,   Gaucher  type,  in  brother 

and  sister. 

postmortem,  its  etiology  is  still  shrouded  in  mystery.  It  is  generally 
overlooked  in  early  infancy,  or  the  splenic  and  hepatic  enlargement 
is  attributed  to  rachitis,  splenic  anemia  or  syphilis.  As  the  child 
groAvs  older,  it  is  found  that  notwithstanding  good  hygienic  care  and 
treatment,  the  affected  organs  assume  greater  dimensions,  often  oc- 
cupying the  entire  abdominal  cavity.     (Fig.  157.)     In  addition  to  this 


DISEASES    OF    THE    BLOOD   AND    DUCTLESS   GLANDS 


559 


symptom  the  patient  usually  suffers  from  anemia,  and  its  accompany- 
ing* manifestations';  occasional  hemorrhaoe  from  the  nose  and  mouth; 
pigmentation  of  the  skin,  and  enlargement  of  the  lymph  nodes.  The 
disease  usually  proceeds  a  chronic  course  and  is  sometimes  marked 
by  remissions  or  even  spontaneous  arrest  of  further  enlargement.  In 
the  majority  of  instances,  however,  death  supervenes  within  from 
two  to  ten  years  as  a  result  of  passive  congestion  of  the  different  ad- 
jacent organs  which  are  displaced  and  pressed  upon  by  the  ever- 
growing spleen  and  liver. 

A  correct  diagnosis  can  most  frequently  be  made  by  excluding 
syphilis  (Wassermann  reaction  positive),  tuberculosis  (tuberculin  test 
positive),  splenic  anemia  (definite  blood  changes,  liver  usually  free), 
and  Banti's  disease  (spleen  but  moderately  enlarged,  usually  ascites, 
not  congenital,  nor  a  family  affection). 

Early  splenectomy  is  the  only  procedure  that  offers  any  prospect  of 
recovery.  Cases  in  which  the  splenic  enlargement  progresses  very 
slowly  are  best  let  alone. 

Postmortem  examination  usually  discloses  an  endothelial  hyper- 
plasia in  the  spleen,  liver,  lymph  nodes  and  bone  marrow.  To  give  a 
definite  idea  of  the  enormity  of  the  splenic  enlargement  in  this  affec- 
tion I  may  add  that  in  a  case  of  a  thirteen-year-old  girl  reported  by 
Bovaird  (Am.  Jour.  Med.  Sc,  1900),  the  spleen  weighed  I2V2  pounds. 

Adenitis  and  Lymphadenitis 

Acute  and  chronic  involvement  of  the  lymph  glands  are  of  quite 
common  occurrence  in  children.  We  may  classify  them  in  accord 
with  their  etiology  as  follows:* 

(a)   Trauma  and  skin  diseases 
(ft)   Nasopharyngeal  disease 

(c)  Dental  caries  and  stomatitis 

(d)  Acute  infectious  diseases, 
more  particularly  glandu- 
lar fever,  German  measles 

(a)  Hyperplasia  following  acute 
lymphadenitis 

(b)  Syphilis 

(c)  Tuberculosis  (scrofulosis) 

(d)  Leukemia  and  pseudoleuke- 
mia 


Inflammations 


Acute  lymphadenitis  due  to 
local  infections 


Chronic  lymphadenitis 


Tumors 


Lymphosarcoma 
Malignant  lymphoma 
\  Chloroma 

Secondary  malignant  tumor 


( Carcinoma 
)  Sarcoma 


"Diagram  modified  after  A.  Caille. 


560 


DISEASES   OF    CHILDREN 


The  glands  most  frequently  affected  are  the  cervical,  submaxillary, 
submental,  axillary,  peribronchial,  mesenteric  and  in^ninal.  Ordi- 
narily with  removal  of  tlie  cause,  the  glandular  enlargement  gradually 
disappears;  in  a  number  of  cases,  however,  they  remain  permanently 
indurated. 

1.  Diseases  cf  the  ear  (auditory  meatus),  eruptions  above  the  face,  and  occa- 
sionally during  parotiditis. 

2.  Mastoiditis  and  infections,  and  erujjtions  affecting  the  scalp. 

3.  Infections  of  the  chin,  tongue  and  lower  lip. 

4.  Infections  of  the  mouth  and  teeth,  stomatitis,  rubeola  and  rul)ella. 

5.  Infections  of  the  tonsils,  in  the  mild  attacks  of  scarlet  fever  and  at  first  in 
variola.    In  severe  scarlet  fever  5,  6,  7  and  8  may  be  much  affected. 


Fig.  159. 


Fig.  160. 


Figs.   159   and   160. — Distribution   of   the   principal   lymphatic   glands   of    the    neck 

and  trunk. 


6.  Pharyngeal  infections  and  inflammation,  therefore  in  retropharyngeal   lymph- 
adenitis.   Also  in  severe  scarlet  fever  and  rubella. 

7.  Infections  of  the  scalp  and  scarlet  fever. 

8.  During  the   course  of   diphtheria,   4,   5,   6,   7   and   8   may  become  prominently 
enlarged,  so  that  the  whole  neck  appears  badly  sw^ollen  and  tender. 

9.  Infections  of  the  neck  and  occasionally  during  the  course  of  diphtheria. 

10.  Infections  affecting  the  arm,  the  axilla  and  the  upper  portions  of  the  chest 
anteriorly  and  posteriorly. 

11.  Infections  of  the  hand,  and  especially  of  the  three  inner  fingers;   quite  fre- 
quently this  is  enlarged  during  the  course  of  a  syphilitic  eruption. 

12.  Infections  affecting  the  lower  limbs,  particularly  the  thigh  and  sometimes  dur- 
ing the  course  of  syphilis.     In  rare  instances  these  glands  are  affected  in  rubella. 

Treatment. — Attention  to  primary  cause;  ice  bag  to  the  swelling  or 
an  ointment  of  plumbum  iodide  or  ichthyol.    If  the  swelling  persists, 


DISEASES   OF    THE    BLOOD    AXD   DUCTLESS   GLANDS  561 

hot  compresses  to  hasten  suppuration,  incision  and  drainage.  Tuber- 
culous glands  are  noAvadays  let  alone  until  they  show  signs  of  break- 
ing down.  The}'  are  then  incised  and  drained.  In  some  of  these  cases 
tuberculin  treatment  (g.  v.)  seems  to  do  good.  Glands  that  give  rise 
to  persistent  constitutional  symptoms  should  be  removed.  Syrup  of 
iodide  of  iron  and  cod  liver  oil  often  act  very  beneficially. 

DISEASES  OF  THE  THYROID  GLAND 

The  normal  thyroid  gland  is  somewhat  larger  in  children,  especially 
girls,  than  in  adults.  It  consists  of  three  lobes,  one  middle  small 
lobe  (inconstant)  and  two  larger  lateral  lobes.  The  latter  are  con- 
nected by  an  isthmus.  The  lateral  lobes  are  situated  on  each  side  of 
the  trachea  along  the  second  and  third  tracheal  rings;  the  middle  lobe 
lies  in  front  of  the  thyroid  cartilage  and  ascends  upward  in  the  direc- 
tion of  the  middle  of  the  hyoid  bone.  As  the  gland  is  thin  and  often 
lies  deeply  imbedded  in  the  neck,  it  is  very  rarely  possible  by  palpa- 
tion to  determine  the  size  of  a  normal  thyroid. 

Thyroiditis 

(Strumitis) 

Primary  inflammation  of  the  thyroid  gland  is  usually  of  traumatic 
origin  (direct  violence,  or  injury  during  delivery).  It  is  of  very  rare 
occurrence.  More  frequently  we  meet  with  secondary  thyroiditis,  as 
a  rule,  in  connection  with  acute  exanthematous  diseases  and  occasion- 
ally with  parotitis,  malaria,  and  articular  rheumatism. 

The  symptomatology  consists  of  swelling  of  the  gland,  pain  on 
pressure  as  well  as  on  moving  the  neck,  and  in  some  cases  redness, 
fluctuation  and  suppuration,  and  more  or  less  marked  pressure  symp- 
toms. 

The  inflammation  usually  disappears  under  local  application  of 
cold.  Should  an  abscess  form,  it  demands  immediate  evacuation  of 
the  pus  and  drainage. 

Severe  protracted  thyroiditis  not  rarely  leads  to  atrophy  of  the 
gland. 

Goiter 

(Struma) 

As  in  adults,  the  thyroid  gland  of  children  is  subject  to  hyperplasia 
and  cystic  degeneration.  In  countries  where  goiter  is  endemic  it  is 
not  rarely  observed  in  very  young  infants,  and  is  probably  of  ante- 


562 


DISEASES   OF    CHILDREN 


natal  origin.  On  the  other  hand,  sporadic  goiter,  as  a  rule,  develops 
at  the  period  of  puberty,  particularly  in  girls. 

Small  goiters  may  remain  free  from  any  manifestations,  except  the 
local  swelling  in  the  anterior  portion  of  the  neck,  while  goiters  large 
enough  to  exert  pressure  upon  the  adjacent  structures  may  prove  a 
menace  to  life  by  compression  of  the  trachea,  and  the  large  blood 
vessels  and  nerves  which  abound  in  the  neck.  The  pressure  symp- 
toms ordinarily  consist  of  headache,  dizziness,  aphonia,  dyspnea  and 
paroxysmal  cough.  This  grave  symptom  complex,  however,  is  of 
unusual  occurrence. 

On  the  whole,  the  prognosis  is  favorable.  The  great  majority  of 
eases   of  goiter  yield  promptly  to   internal  administration   of  small 


Fig.  161. — Goiter  in  girl  eleven  years  old. 

doses  of  iodine,  with  or  without  thyroid  or  parathyroid  gland  sub- 
stance, and  external  use  of  iodine  ointment.  Large  goiters,  causing 
marked  pressure  symptoms,  call  for  their  extirpation. 

In  countries  where  goiter  is  endemic  its  development  to  a  great  ex- 
tent may  be  prevented  by  change  of  residence,  by  boiling  the  drink- 
ing water,  and  by  drinking  large  quantities  of  distilled  water. 

In  infants  goiter  may  be  mistaken  for  a  large  hygroma  cysticum 
colli  congenitum  or  other  cysts  of  the  neck,  and  in  older  children  for 
exophthalmic  goiter.  Cysts  of  the  neck  are  characterized  by  marked 
fluctuation  and  rapid  development,  and  usually  start  from  the  sub- 
maxillary region. 


DISEASES    OP    THE    BIjOOD    AND   DUCTLESS   GLANDS 


5G3 


Exophthalmic  Goiter  (Basedow's  or  Graves's  Disease) 

It  is  characterized,  in  addition  to  the  goiter,  by  tachycardia,  muscular 
tremor,  exoplithalmos,  Graefe's  symptom,  general  ill  health,  vasomotor 
disturbances  (flushes  of  the  skin  alternating  with  pallor),  and  pig- 
mentation of  the  skin.  Rapid  growth  in  height  is  not  an  uncommon 
manifestation. 

Treatment. — Absolute  rest  to  body  and  mind.  Small  doses  of  atro- 
pine to  subdue  excessive  activity  of  the  thyroid.  Bromide  and  dig- 
italis for  tachycardia  and  tremor.  Attention  to  tonsils,  teeth  and  other 
sources  of  irritation. 

Cretinism 
(Endemic  or  Goitrous  Cretinism,  Sporadic  Cretinism 

AND  MyXIDIOCY) 

Cretinism  is  due  to  partial  or  total  arrest  of  the  secretion  of  the 
thyroid  gland,  in  consequence  of  congenital  or  acquired  (extirpation) 
absence,  atrophy  (from  strumitis,  syphilis,  tuberculosis,  or  neo- 
plasms), or  goitrous  degeneration  of  the  gland. 


rig.   162. — Hypothyroidism — Myxidiocy,  in   a  girl  sixteen  years  old. 


564 


DISEASES    OF    CHILDREN 


Endemic  cretinism  occurs  in  children  living  in  countries  where 
goiter  is  endemic,  or  in  descendants  of  people  coming  from  these  re- 
gions, and  is  very  frequently  associated  with  goiter.  On  the  other 
hand,  sporadic  cretinism  is  observed  in  children  coming  from  other 
parts  of  the  world.  The  term  "myxidiocy"  is  usually  reserved  for 
the  pronounced  forms  of  cretinism  which  are  associated  with  marked 
pseudolipomatosis.     (For  full  description  of  ''Cretinism,"  see  p.  721.) 

DISEASES  OF  THE  THYMUS  GLAND 

The  thymus  gland  consists  of  two  lateral  lobes  coming  in  close 
contact  along  the  middle  line.     It  is  situated  in  the  anterior  portion 


Fig.  163. — Large  thymus. 

of  the  neck  and  superior  mediastinum,  extending  from  the  lower 
border  of  the  thyroid  gland  to  the  upper  border  of  the  fourth  rib. 
The  thymus  varies  greatly  in  size  and  weight.  It  is  about  2i/2 
inches  in  length,  II/2  inches  in  width  (at  its  lower  portion),  and 
1/4  of  an  inch  in  thickness.  It  attains  its  greatest  development 
(weighing  %  ounce)  between  the  first  and  second  years,  and 
undergoes  rapid  degeneration  soon  after  puberty,  so  that,  at  the 
age  of  twenty,  it  is  a  mere  vestige  of  lymphoid  tissue  and  fat.  In 
children  under  six  years  of  age,  light  percussion  over  the  supe- 
rior mediastinum  reveals  a  triangular  field  of  dulness,  its  base  be- 
ing on  a  line  with  the  sternoclavicular  articulations,   and  its  apex 


DISEASES    OF    THE    BLOOD    AND    DUCTLESS    GLANDS  565 

the  second  rib.  It  is  well  to  remember,  however,  that  similar  diilness 
is  obtained  in  enlarged  bronchial  glands. 

We  have  yet  a  great  deal  to  learn  about  the  status  of  the  thymus 
gland  in  the  human  economy.  Though  fully  dispensable  in  adult  life, 
it  is  essential  to  the  growth  and  development  of  the  child.  The  func- 
tion of  the  thymus  is  more  or  less  dependent  upon  and  in  part  regu- 
lated by  that  of  the  thyroid,  and  vice  versa.  Thus,  there  is  less  need 
of  thymus  when  the  thyroid  is  gone,  and  similarly  less  thyroid  suffices 
Avhen  the  thymus  is  removed.  INIoreover  in  cases  of  hypertrophy  of 
the  thymus,  where  the  elaboration  of  its  secretion  is  excessive,  re- 
moval of  the  thyroid  is  usually  followed  by  sudden  death,  which 
shows  plainly  that  in  the  absence  of  the  regulating  power  of  the 
thyroid  an  excess  of  thymus  secretion  is  destructive  to  the  human 
economy.  Experiments  on  dogs  by  H.  Klose*  have  show^n  that  about 
two  weeks  after  total  removal  of  the  thymus  gland  a  "stadium  adi- 
positas"  of  from  two  to  three  months'  duration  develops,  followed 
by  loss  in  weight,  general  bodily  weakness,  frailty  of  the  bones,  ar- 
rest of  growth  in  spite  of  ravenous  appetite,  and  frequently  sponta- 
neous fractures.  This  cachectic  state,  or  cachexia  thymopriva  is  ac- 
companied by  idiotin  thymopriva  with  a  terminal  coma  thymicum. 
Postmortem  examination  discloses  signs  of  rachitis,  osteomalacia  and 
osteoporosis,  the  lime  salts  content  being  reduced  to  about  half  its 
normal  percentage,  although  the  ratio  of  the  lime  salts  was  unaltered. 
According  to  the  same  author  the  deficiency  in  undissolved  lime  salts 
is  dependent  upon  an  increased  acid  action  owing  to  the  failure  of 
the  thymus  to  inhibit  the  formation  of  acids  in  the  organism  or  to 
neutralize  or  mask  an  excess  thereof.  This  "hypothetic"  nucleinic 
acid  intoxication,  he  believes,  produces  in  growing  bone  defective 
construction,  rachitis  with  abnormal  softness  and  flexibility,  while  in 
fully  formed  bone  increased  destruction,  osteomalacia,  and  osteo- 
porosis with  abnormal  fragility. 

With  these  laboratory  observations  in  view  we  are  enabled  to  ob- 
tain a  clearer  conception  of  the  manifestations  accruing  from  the 
effects  of  thymus  disease  or  congenital  abnormality,  be  it  hyperplasia 
or  hypoplasia  of  the  thymus. 

Like  other  glands  of  the  body  the  thymus  gland  is  subject  to  acute 
and  chronic  inflammation  (thymitis)  with  consecutive  hyperplasia, 
or  premature  atrophy;  tuberculosis;  syphilis,  and  neoplasms. 


'Brooks   and   Langerhans'   "Text-Book   of   Pathology." 


566  DISEASES   OF    CHILDREN 


Acute  Thymitis 


Acute  thymitis  is  a  rare  affection,  generally  occurring  only  in  young 
infants.  The  etiology  is  obscure:  in  some  cases  a  history  of  naso- 
pharyngeal infection  is  elicited.  It  is  also  claimed  that  thymitis  may 
develop  secondarily  to  a  systemic  pyemic  process  or  by  extension  of 
inflammation  from  adjacent  structures.  The  symptomatology  is  usu- 
ally indefinite,  except  where  the  thymus  attains  an  enormous  size 
and  gives  rise  to  pressure  symptoms  on  the  larnyx,  esophagus,  and  the 
large  blood  vessels  in  the  mediastinum,  etc.  The  case  presently  to  be 
related  may  offer  a  general  idea  of  the  puzzling  symptom  complex. 
The  baby  was  four  weeks  old,  normal  at  birth  and  nursed  by  the 
mother.  It  was  circumcised  when  eight  days  old,  and  did  well  very 
soon  after.  The  day  before  coming  under  my  observation  it  was  very 
restless,  and  towards  evening,  while  at  the  breast,  suddenly  dropped 
the  nipple,  gave  a  sharp  loud  cry,  snapped  the  jaws  tightly  together, 
and  seemed  to  lose  consciousness.  A  neighboring  physician  who  was 
immediately  consulted,  did  not  venture  to  express  a  definite  opinion, 
but  prescribed  calomel  and  an  intestinal  irrigation.  The  next  day  I 
found  the  baby  in  the  following  condition.  The  baby  looked  well 
nourished  and  otherwise  normal  in  appearance.  It  lay  perfectly  still 
with  its  eyes  widely  open.  There  was  neither  rigidity  of  the  neck, 
nor  any  other  sign  (Brudzinski,  Kernig,  etc.)  of  disease  of  the  nervous 
system.  The  respirations  ranged  between  70  and  80  per  minute,  and 
were  acompanied  by  an  expiratory  moan.  The  heart  beat  ranged 
between  120  to  130  per  minute.  Both  the  lungs  and  heart  were  ab- 
solutely free  from  any  abnormal  physical  signs.  The  liver  and  spleen 
were  normal  in  size.  The  urine  although  greatly  suppressed  in  the 
beginning,  showed  no  abnormal  constituents.  There  was  relative  con- 
stipation, but  the  bowels  moved  with  enema.  The  abdomen  was  soft 
and  free  from  any  tumefaction.  The  blood  was  negative  except  for 
a  high  leucocytosis.  The  temperature  was  below  100°  F.,  but  rose  to 
102°  and  103°  F.  a  few  days  later.  The  jaws  remained  somewhat  rigid, 
and  the  baby  refused  to  nurse  at  the  breast.  He  swalloAved  milk 
dropped  in  his  mouth,  apparently  with  ease,  in  the  first  three  or  four 
days  of  his  illness,  but  with  difficulty  towards  the  end.  At  this  time 
attacks  of  asphyxia  and  continued  cyanosis  also  set  in.  The  baby 
was  ill  six  daj^s  and  died  without  a  struggle.  The  two  learned  ped- 
iatrists  whom  I  consulted  on  the  case,  like  myself,  failed  to  arrive  at 
a  correct  diagnosis.  "We  all  suspected  a  toxic  condition  of  the  blood, 
but  never  thought  of  the  thymus  gland.  Some  time  later  I  had  the 
opportunity  to   discuss   the   case   with  Dr.   Charles   G.   Kerley,   who 


DISEASES   OF    THE    BLOOD    AND   DUCTLESS   GLANDS  567 

kindly  informed  me  that  lie  had  seen  a  few  cases  of  the  kind  at  the 
Babies'  Hospital  and  that  postmortem  examination  disclosed  acute 
inflammation  of  the  thymus  gland.  I  firmly  believe  Ave  Avere  dealing 
with  just  such  a  case. 

Acute  thymitis  sometimes  leads  to  suppuration  of  the  gland. 

Chronic  Thymitis 

Chronic  thymus  disease  is  variously  attributed  to  lung  and  heart 
disease,  pertussis,  rubeola,  diphtheria,  scarlatina,  asphyxia  neona- 
torum, tuberculous  and  syphilitic  processes,  and  malignant  growths, 
but  excepting  the  last  three  etiologic  factors,  the  manifestations  pro- 
duced by  the  other  causes  are  undoubtedly  only  transient  in  character. 
The  same  is  true  of  atrophy  of  the  thymus  associated  with  protracted 
malnutrition.  Indeed,  it  has  been  shown  that  the  atrophied  gland  in 
emaciation  is  often  regenerated  on  restoration  of  the  body  weight.  I 
am  inclined  to  believe,  therefore,  that  genuine  hypo-  or  hyperplasia  of 
the  thymus  is  due  either  to  a  primary  congenital  anomaly  of  the  thy- 
mus, or  develops  later  secondarily  to  alterations  in  the  thyroid  or  other 
lymphatic  gland. 

Whatever  the  cause,  the  clinical  syndromes  arising  from  the  effects 
of  hypo-  or  hyperplasia  of  the  thymus  are  not  as  difficult  of  recognition 
as  was  formerly  believed.  As  already  stated  the  functions  of  the 
thymus  and  thyroid  glands  are  closely  correlated,  so  that  hypoplasia 
of  the  thymus  by  inducing  also  a  reciprocal  diminution  in  the  thyroid 
secretion  produces  not  only  an  arrest  of  growth  and  frailty  of  the 
bones  and  general  debility,  but  also  lowered  mental  capacity  as  ex- 
emplified in  infantilism,  more  especially  in  the  Brissaud  and  Lorain 
types. 

The  clinical  signs  of  hyperplasia  differ  with  the  degree  of  the  thymic 
enlargement  and  the  functional  activity  of  the  thymus.  Not  every 
case  of  thymus  hypertrophy  is  necessarily  associated  with  increased 
function  of  the  gland.  The  latter  may,  for  example,  owe  its  enlarge- 
ment to  a  growth  destroying  the  medullary  substance  of  the  gland, 
and  thus  be  incapacitated  rather  than  hyperactivated.  Even  where  the 
thymus  secretion  is  excessive,  the  symptoms  engendered  vary  greatly. 
By  corresponding  increased  activity  of  the  thyroid  the  clinical  picture 
may  be  limited  to  that  observed  in  hyperthyroidism,  i.  e.,  tachycardia, 
insomnia,  change  in  disposition,  abnormal  perspiration,  and  often  also 
a  mild  degree  of  exophthalmos  and  possibly  struma. 

In  another  group  of  cases  of  hyperplasia  of  the  thymus  careful 
examination  of  the  child  fails  to  reveal  any  definite  manifestations 
of  a  pathologic  entity,  except  possibly  a  few  signs  of  anemia  with 


568  DISEASES   OF    CHILDREN 

adipositas,  rachitis,  or  "scrofiilosis,"  but  this  notwithstanding,  death 
may  occur  without  any  apparent  reason  as  the  result  of  slight  causes 
(e.  g.,  serum  injection,  narcosis,  slight  operations,  etc.)  which  produce 
physical  excitement  or  shock  and  are  usually  of  no  consequence  in 
healthy  children.  This  condition  is  generally  spoken  of  as  status 
lymphaticus  or  lymphatism.  Unfortunately,  we  have  no  characteristic 
symptoms  by  means  of  which  this  condition  may  be  diagnosed  during 
life  and  nothing  characteristic  is  found  at  necropsy. 

Finall}^,  in  another  group  of  cases  hyperplasia  of  the  thymus  percus- 
sion reveals  marked  dulness  over  the  upper  portion  of  the  sternum 
particularly  to  the  left  as  low  as  the  second  rib  and  often  also  to  the 
back  between  the  scapulae.  It  is  in  addition  distinguished  by  the 
presence  of  swollen  lymph  glands  in  the  lateral  lower  region  of  the 
neck,  which  may  sometimes  be  seen  to  continue  deeply  down  between 
the  clavicle  and  side  of  the  sternum.  If  the  hypertrophy  is  of  long 
standing  we  readily  detect  secondary  manifestations,  such  as  dilata- 
tion of  the  veins  of  the  neck,  dislocation  of  the  heart,  accentuation  of 
auscultatory  signs  of  the  heart  and  lungs  and  arching  and  distention 
of  the  thorax.  The  thymus  gland  may  occasionally  be  felt  in  the 
middle  line  above  the  incisura  sterni  as  an  arched  elastic  swelling, 
which  may  ascend  upward  to  the  thyroid  gland.  Furthermore,  the 
thymus  enlargement  is  distinctly  discernible  by  means  of  the  Roentgen 
rays.  The  clinical  signs  differ,  of  course,  with  the  degree  of  mechan- 
ical encroachment  upon  the  adjacent  structures  (thyroid,  blood  ves- 
sels and  nerves,  trachea  and  bronchi)  and  secondary  involvement  of 
the  heart  and  lungs.  As  a  rule,  the  symptomatology  is  essentially 
that  of  cardiac  asthma,  so-called,  and  is  generally  spoken  of  as  asthma 
thymicum.  The  child  is  suffering  from  a  persistent  cough  and  other 
signs  of  bronchitis,  marked  dyspnea,  cyanosis  or  marked  pallor  of 
the  face  and,  off  and  on,  Avith  acute  turgescence  of  the  enlarged  thy- 
mus, it  is  attacked  by  paroxysms  of  asphyxia  which  not  rarely  termi- 
nate fatally.  Pott,*  who  has  frequently  observed  the  course  of  these 
fatal  attacks  of  asphyxia,  describes  them  as  follows.  The  children 
bend  their  heads  suddenly  backward  (which  position,  by  the  way,  by 
producing  a  marked  lordosis  of  the  cervical  region  of  the  spine  and 
thus  increasing  the  pressure  of  the  thymus  against  the  trachea  greatly 
aggravates  the  laryngospasm),  and  make  soundless,  gasping  inspira- 
tory movements.  The  eyes  are  turned,  the  face  is  blue  or  black,  the 
cyanotic  tongue  is  impacted  between  the  jaws,  the  veins  of  the  neck 
are  distended,  the  hands  are  clinched,  the  forearms  are  pronated 
and  abducted,  the  legs  are  stiff  and  extended,  the  large   toes  are 


•Graetzer  and   Sheffield's   Practical    Pediatrics,   p.   296. 


DISEASES    OF    THE    BLOOD   AND    DUCTLESS   GLANDS  569 

abducted  and  flexed,  and  the  spine  is  arched  strongly  backward. 
The  pulse,  heart's  action,  and  heart  sounds  cease  immediately  Avitli 
the  onset  of  the  paroxysm,  and  after  a  few  futile  respiratory  efforts 
the  face  turns  ashy  in  color  and  in  a  minute  or  two  the  child  is  a 
corpse.  Pott  believes  to  have  felt  the  vocal  cords  snugly  together 
in  the  median  line.  He  nevertheless  maintains  that  death  is  caused 
by  heart  failure  and  not  by  closure  of  the  glottis,  for  on  two  occa- 
sions he  performed  immediate  tracheotomy  by  one  incision  without 
any  relief.  This  view  is  not  shared  by  all  observers,  and  Biedert,  for 
example,  is  of  the  opinion  that  closure  of  the  glottis,  through  suffo- 
cation stasis  in  the  heart  and  thymus  might  be  responsible  for  the 
onset  of  such  an  attack  and  its  grave  result.  Of  course,  not  all  at- 
tacks terminate  immediately  fatally.  Some  time  ago  I  had  the  op- 
portunity, for  several  weeks,  to  watch  a  five-months-old  infant 
afflicted  with  an  apparently  congenital  hyperplasia  of  the  thymus. 
The  family  history  was  negative  as  regards  syphilis  and  tuberculosis. 
The  father,  a  French  artist,  was  in  perfect  health,  the  mother  was 
subject  to  arthritis  with  slight  valvular  heart  disease.  The  older 
child,  who  is  now  ten  years  old,  was  for  four  months  suffering  from 
spasmodic  pyloric  stenosis.  The  infant  under  consideration  weighed 
about  5  pounds  at  birth  and  failed  to  gain  though  breast-fed  for  the 
first  three  months  of  its  life.  It  was  noticed  immediately  after  birth 
that  he  was  very  pale  and  cyanotic,  had  some  difficulty  in  breathing, 
coughed  a  little  and  had  a  husky  cry.  Gradually  these  symptoms 
became  worse  and  attacks  of  bronchitis  with  marked  dyspnea  set  in, 
during  which  the  baby  would  repeatedly  be  seized  by  convulsions 
with  loss  of  consciousness.  The  family  physician  diagnosed  it  as 
asthma,  while  a  very  learned  pediatrist  decided  that  they  were  deal- 
ing with  spasmus  glottidis  supervening  faulty  feeding.  The  child's 
condition  got  gradually  worse,  notwithstanding  the  correction  of  diet 
and  administration  of  antispasmodics,  etc.  When  I  saw  it  the  clini- 
cal picture  resembled  pulmonary  edema,  but  there  were  no  signs  of 
primary  heart  or  kidney  disease  and  the  history  of  the  case  and  the 
distinct  hoarseness  certainly  pointed  to  some  form  of  immediate 
obstruction  in  the  upper  respiratory  tract — most  probably  primary, 
nay  congenital,  since  it  was  manifested  at  birth.  There  Avas  no  diffi- 
culty to  exclude  asthma,  as  this  disease  is  invariably  associated  with 
remissions  and  would  at  least  temporarily  yield  to  antiasthmatic 
remedies  which  in  this  case  were  given  a  fair  trial.  Neither  did  the 
diagnosis  of  spasmus  glottidis  appeal  to  me.  Here  the  infant  is  free 
from  dyspnea,  etc.,  between  each  paroxysm,  and  certainly  does  not 
get  worse  on  a  suitable  diet.     Going  over  the  case  more  carefully  I 


570 


DISEASES   OF    CHILDREN 


detected  undue  dulness  over  the  upper  portion  of  the  sternum,  marked 
dilatation  of  the  veins  in  the  neck,  fulness  of  the  neck  over  the  inter- 
clavicular notch — all  signs  and  symptoms  which  were  quite  suggest- 
ive of  thymus  hypertrophy.  I  therefore  suggested  a  Roentgen-ray 
examination,  which  promptly  confirmed  my  diagnosis.  Tlie  infant 
was  in  too  delicate  a  condition  to  undergo  thymectomy,  and  his  par- 
ents— rightly— hesitated  to  consent  to  this  procedure.  The  infant 
was  soon  relieved  of  its  agony  during  a  paroxysm  of  asphyxia. 

Treatment. — Acute  thymitis,  if  detected  early  may  occasionally  be 
arrested  in  its  progress  by  an  ice  bag,  and  in  strong  infants  a  few 


Fig.  164. — Precocious  child  eight  years  old;   began  to  menstruate   when   about  five 
years  old   (hyperpituitaria?). 


leeches  over  the  manubrium  sterni,  and  internal  administration  of 
calomel.  In  chronic  thymus  hypertrophy,  if  severe  in  character, 
partial  or  even  complete  removal  of  the  thymus  is  absolutely  indis- 
pensable. Before  resorting  to  an  operation,  however,  we  must  as- 
certain that  Ave  are  not  dealing  with  a  syphilitic  condition,  which 
may  be  remedied  by  antisyphilitic  medication.  Sudden  attacks  of 
asphyxia  calls  for  prompt  tracheotomy  or  intubation  and  antispas- 


DISEASES    OF    THE    BLOOD    AND   DLX'TLESS   GLANDS  571 

modies  (bromides,  codeine).  In  hypoplasia  of  the  thymus,  some  bene- 
fit may  possibly  be  derived  from  internal  administration  of  thymus 
gland,  from  10  to  30  grains  daily. 

Disease  of  the  Pituitary  Gland,  or  Hjrpophysis  Cerebri 

CHyperpituitarla.;     Hypopituitaria  ;     Dystrophia     Adiposogenitalis, 

Frohlich) 

The  pituitary  body  consists  of  an  anterior,  middle  and  posterior 
portion,  and  is  situated  at  the  base  of  the  brain,  resting  upon  and 
slightly  surrounded  by  the  sella  turcica.  Disturbances  in  the  function 
of  the  anterior  portion  of  the  hypoph^'sis  give  rise  to  gigantism  in 
children  and  acromegaly  in  adults,  while  disturbances  in  the  function 
of  the  posterior  (or  both  anterior  and  posterior)  portion  of  the  hypo- 
physis leads  to  dystrophia  adiposogenitalis,  a  clinical  syndrome  first 
described  by  A.  Frohlich  in  1911.  This  clinical  entity  is  manifested  by 
retarded  growth  and  development,  excessive  adipositas,  sexual  in- 
fantilism, atrophy  of  the  sexual  glands,  polyuria,  subnormal  tempera- 
ture, sluggish  metabolism,  and  high  tolerance  for  carbohydrates  (ex- 
cessive amounts  of  sugar  fail  to  produce  glycosviria). 

In  treating  pituitary  disease  it  is  essential  first  of  all  to  determine 
by  exact  Roentgen-ray  examinations,  whether  or  not  a  hypophyseal 
tumor  is  being  dealt  with.  If  this  be  so,  operative  interference  is 
indispensable,  and  is  nowadays  executed  with  a  fair  amount  of  suc- 
cess. In  the  absence  of  a  tumor,  pituitary  feeding  should  be  resorted 
to,  particularly  in  cases  of  hypo-  and  apituitarism. 


CHAPTER  XI 
DISEASES  OF  THE  KIDNEYS,  BLADDER,  ETC. 

Nephritis  Acuta 

Acute  nephritis  is  most  frequently  met  with  in  association  with 
acute  infectious  and  contagious  diseases,  especially  scarlatina,  diph- 
theria, tonsillitis,  influenza,  and  pneumonia.  Less  frequently  it  occurs  as 
a  result  of  exposure  to  wet  and  cold ;  of  structural  alterations  of  the 
skin,  e.  g.,  extensive  burns;  of  ingestion  of  certain  irritants  to  the 
kidneys,  e.  g.,  cantharides,  potassium  chlorate,  aspidium,  etc.,  ether 
or  chloroform  inhalation,  and,  finally,  not  rarely  it  is  observed  in 
infants  suffering  from  gastroenteric  affections.  The  aforementioned 
causes  usually  operate  upon  both  kidneys,  so  that  both  kidneys  are 
equally  affected.  The  lesion  may,  however,  remain  limited  to  one 
kidney  Avhere  the  disease  is  caused  by  direct,  unilateral  trauma  (di- 
rect violence,  calculus,  etc.).  The  seat  of  the  kidney  lesions  varies 
somewhat  with  the  cause.  For  example,  the  glomeruli  {glomerular 
nephritis)  are  most  severely  involved  in  scarlatina,  while  in  diph- 
theria we  most  commonly  find  degenerative  changes  in  the  renal  tubules 
(degenerative  or  parenchymatous  nephritis).  But  no  particular  form 
of  acute  nephritis  is  peculiar  to  a  given  cause.  In  severe  cases  the 
kidneys  are  greatlj^  increased  in  volume  and  weight.  The  surface 
is  smooth  and  the  capsule  readily  removable.  The  renal  cortex  is 
either  uniformly  reddened  or  pale  and  mottled  with  red.  The  tubuli 
uriniferi  are  partly  or  completely  obstructed  by  large  granular  epithe- 
lial cells,  blood  corpuscles  and  fibrin.  In  the  early  stage  of  the 
disease  the  interstitial  tissue  shows  no  alteration;  in  protracted  cases, 
however,  this  tissue  may  suffer  very  severely.  In  this  event  the  proc- 
ess is  often  spoken  of  as  productive  or  interstitial  nephritis. 

Consonant  with  the  etiologic  factors  we  distinguish  a  primary 
and  secondary  form  of  acute  nephritis,  but,  except  for  some  slight 
difference  in  the  onset  (it  being  more  sudden  in  primary  nephritis), 
the  symptomatology  is  practically  the  same  in  both  varieties.  The 
child  complains  of  headache,  backache,  dizziness,  nausea  and  chilli- 
ness, occasionally  vomits,  and  in  severe  forms  shows  other  symptoms 
of  grave  constitutional  disturbance.  Not  infrequently  attention  to 
the  illness  is  not  attracted  until  the  appearance  of  pronounced  anemia 

572 


DISEASES   OF    THE    KIDXEYS   AXD    BLADDER 


573 


and  piiffiness  of  the  eyelids,  or,  especially  in  infants,  the  occurrence 
of  partial  or  total  suppression  of  urine  with  or  without  uremic  symp- 
toms. Examination  of  the  urine  discloses  more  or  less  marked  al- 
teration in  its  constituents.  Chemically,  the  urine  almost  invariably 
reveals  the  presence  of  a  variable  amount  of  albumin,  and,  micro- 
scopically, casts  of  all  sorts,  especially  hyaline,  red  and  white  blood  cor- 
puscles, epithelium,  detritus,  etc.  The  urine  is  usually  acid,  and  its 
specific  gravity  high,  the  latter  being,  of  course,  most  marked  when 
the  quantity  is  verj'  small.     The  excretion  of  urea  is  diminished.     In 


Fig.  165. — Acute  nephritis  with  general 
anasarca  in  a  four-month-old  infant.  Note 
"pitting"    on   pressure  with   finger. 


Fig.   166. — Same   case  as   Fig.   165 
three  weeks  later. 


severe  inflammation  of  the  kidneys  the  urine  contains  a  large  quantity 
of  blood  {hemorrhagic  nephritis),  and  is  dark-red  or  smoky  in  color. 
As  already  alluded  to,  the  onset  of  nephritis  often  escapes  detection. 
This  is  especially  true  in  the  secondary  form.  Hence  the  importance 
of  systematic  examination  of  the  urine  during  the  course  of  acute 
communicable  diseases.  It  is  well  to  remember,  however,  that  not 
every  all5uminuria  is  of  nephritic  origin.  A  small  quantity  of  albumin 
and  a  few  casts  are  not  rarely  found  in  acute  febrile  diseases  (e.  g., 


574 


DISEASES   OP    CHir.DREN 


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DISEASES   OF    THE    KIDXEYS    AND   BLADDER  0/0 

ill  tlie  beginning  of  scarlatina)  "without  kidney  lesions  and  are  only 
transitory  in  natnre. 

Cases  running  a  favorable  course  begin  markedly  to  improve  after 
about  two  weeks.  The  albumin  diminishes,  the  urine  increases  in 
quantity,  becomes  light  and  clear,  and  the  microscopic  abnormal 
constituents  subside.  Edema,  if  present,  is  slight,  and  usually  limited 
to  the  eyelids  and  rapidly  disappears  with  the  improvement  of  the 
other  symptoms. 

Less  favorable  cases  are  of  longer  duration.  From  day  to  day 
the  edema  assumes  wider  dimensions,  involving  the  dorsi  of  the  feet, 
the  legs,  the  genitalia,  and,  if  not  checked,  the  serous  effusion  may 
rapidly  fill  the  abdominal  and  thoracic  cavities.  In  the  majority  of 
instances,  however,  gradual  recovery  from  the  immediate  attack  oc- 
curs, although  in  these  cases  a  relapse  must  always  be  apprehended. 

Another  group  of  cases  is  characterized  by  great  diminution  of 
urine  (oliguria)  or  total  suppression  and  consecutive  uremia.  The 
latter  is  manifested  by  intense  headache,  dizziness,  vomiting,  dimness 
of  vision  up  to  total  blindness,  disturbance  of  hearing,  slight  twitch- 
ing up  to  repeated  attacks  of  severe  convulsions,  slow,  irregular 
pulse,  dA^spnea,  somnolence,  sopor  and  possibly  coma  and  death. 

The  incipient  symptoms  of  nephritis  offer  no  reliable  indications 
as  to  the  further  course  of  the  disease.  Scarlatinal  nephritis,  for  ex- 
ample, ushers  in  with  vomiting,  intense  headache,  convulsions,  local 
or  general  dropsy,  and  yet  often  clears  up  completely  within  two  or 
three  weeks;  and,  conversely,  nephritis  may  set  in  insidiously,  appar- 
ently free  from  any  alarming  symptoms,  and,  nevertheless,  proceed 
a  very  protracted  course  and  possibly  lead  to  permanent  degeneration 
of  the  kidney  structures.  Furthermore,  relapses  may  complicate  mat- 
ters, often  when  recovery  is  imminent. 

The  prognosis,  therefore,  should  always  be  guarded,  even  though 
the  general  condition  of  the  patient  is  good.  Even  in  mild  cases 
untoward  complications  are  apt  to  supervene.  Serous  effusions  in 
internal  cavities  are  not  rare.  This  is  true  especially  of  ascites,  less 
frequently  of  pleural  or  pericardial  effusions.  The  heart  rarely  es- 
capes involvement.  Hypertrophy  of  the  heart  is  quite  common,  and, 
if  the  nephritis  runs  a  protracted  course,  dilatation  of  the  heart  may 
prove  a  very  dangerous  complication,  particularly  in  view  of  the 
secondary  pulmonary  edema,  which  is  very  prone  to  occur  in  such 
cases,  and  often  proves  fatal.  Extensive  anasarca  Avith  scanty  urine, 
especially  if  ascites  is  associated  with  hydrothorax,  greatly  mars  the 
prognosis.  As  further  complications  we  may  mention  uremia,  pneu- 
monia, edema  of  the   glottis,  severe  intestinal  catarrh,  more  rarely 


576  DISEASES   OF   CHILDREN 

peritonitis,  pericarditis  and  endocarditis  (more  frequent  in  scarlatinal 
nephritis).  Notwithstanding,  however,  the  great  array  of  complica- 
tions, immediate  death  from  acute  nephritis,  especially  the  primary 
variety,  is  not  common.  The  death  rate  ranges  from  between  5  and 
20  per  cent,  the  variation  depending  upon  the  primary  cause,  mode 
of  treatment  and  severity  of  the  complications.  A  great  many  pa- 
tients who  survive  the  acute  stage  remain  invalided  for  life.  As 
we  shall  see  later,  gradual  transition  from  acute  into  chronic  neph- 
ritis is  not  of  uncommon  occurrence.  Convalescence  is  often  pro- 
longed for  weeks  and  months,  and  even  without  permanent  injury  to 
the  kidneys  albumin  may  recur  in  the  urine  from  time  to  time  for  a 
period  of  a  year  or  two  longer  and  continue  to  undermine  the  child's 
constitution. 

Treatment. — Every  ease  of  nephritis,  be  it  ever  so  mild,  should  be 
taken  seriouslj'^,  and  kept  under  strict  observation  not  only  during 
the  active  stage  of  the  affection,  but  for  many  months  after.  During 
the  acute  stage  perfect  rest  in  bed  should  be  enjoined  and  the  diet 
limited  to  bland  articles  of  food  free  from  salt,  preferably  milk  in 
moderate  quantity  with  strained  oatmeal  or  barley,  zwieback  with 
sweet  butter,  stale  bread  with  a  little  apple  sauce,  and  occasionally 
a  little  chicken  soup.  In  the  absence  of  edema  the  drinking  of  water  is 
not  limited,  but,  otherwise,  the  partaking  of  water  should  be  restricted 
to  a  few  tumblerfuls  of  Vichy  or  lithia  water  per  day.  As  the  con- 
dition improves  the  dietary  may  be  augmented  by  the  addition  of 
freshly  boiled — without  salt — vegetables,  such  as  carrots,  spinach, 
cauliflower,  fresh  green  peas,  etc.,  stewed  fruit,  and  freshly  boiled 
whitefish.  The  bowels  should  be  kept  open  by  an  occasional  dose  of 
calomel  followed  by  citrate  of  magnesia  and  by  daily  high  intestinal 
irrigation.  Where  the  excretion  of  urine  is  greatly  reduced  and  the 
dropsy  marked,  energetic  measures  should  be  instituted  without  de- 
lay to  relieve  the  kidney.  This  should  be  attempted,  not,  as  is  fre- 
quently advised,  by  means  of  active  diuretics,  which  only  help  to  in- 
crease the  renal  congestion,  but  by  stimulating  the  activity  of  the 
skin  and  bowels  and  allaying  the  irritation  of  the  kidney.  For  this 
purpose  we  resort  to  hot  packs  (105°  F.),  hot  baths  (103°  F.),  and 
hot  (110°  F.)  rectal  enemas  (to  be  retained  as  long  as  possible)  or 
the  Murphy  drip.  These  may  be  repeated  every  six  hours.  Perspira- 
tion may  be  stimulated  by  small  quantities  of  hot  water,  or  hot  lemon- 
ade. In  hemorrhagic  nephritis  small  doses  of  ergot  act  beneficially. 
Camphor  will  be  found  valuable  to  counteract  collapse,  and  should 
be  administered  hypodermically  in  the  form  of  sterilized  camphor- 


DISEASES   OP    THE    KIDNEYS   AND   BLADDER  577 

atod  oil.  Excessive  irritability  of  the  nervous  system  should  be  com- 
bated by  means  of  the  bromides  and  chloral. 

By  carefully  following  the  aforementioned  directions,  uremia  is 
of  rare  occurrence.  Uremic  convulsions  should  be  controlled  by 
chloroform  inhalation,  hypodermic  injection  of  morphine  and  atro- 
pine (for  a  child  two  years  old  ^32  grain  of  morphine  and  Y^oq  grain 
of  atropine,  if  necessary  to  be  repeated  once  after  two  hours),  and 
where  these  therapeutic  measures  fail,  by  lumbar  puncture. 

Children  recovering  from  nephritis  should  not  be  exposed  to  the  ill 
effects  of  overfeeding,  overexertion,  and  exposure  to  marked  atmo- 
spheric changes.  They  should  wear  light  woolen  underwear,  and,  finan- 
cial means  permitting,  should  spend  the  winter  following  an  acute 
attack  of  nephritis  in  a  warm  climate. 

To  overcome  the  remaining  anemia,  iron  and  cod  liver  oil  will  be 
found  of  service. 

Nephritis  Chronica 

In  the  majority  of  instances  chronic  nephritis  develops  as  a  sequel 
of  the  acute  affection  of  the  kidneys.  The  parenchyma  or  interstitial 
tissue,  or  both,  remain  permanently  impaired.  On  the  one  hand,  we 
may  find  the  kidneys  greatly  enlarged,  the  cortical  portion  increased 
in  volume,  its  surface  white  or  pale-yellow — the  large  white  kidney, 
or  parenchymatous  nephritis;  on  the  other,  the  whole  organ  is  reduced 
in  size,  the  capsule  firmly  adherent,  and  the  surface  irregular  and 
nodular — the  granular  or  cirrhotic  kidney,  or  interstitial  nephritis. 
Amyloid  degeneration  is  another  form  of  chronic  nephritis  in  child- 
hood. It  is  usually  associated  with  amyloid  degeneration  of  the  liver 
and  spleen,  and  ordinarily  occurs  secondarily  to  suppurative  processes 
of  the  bones  or  joints.  Occasionally  chronic  nephritis  is  encountered 
in  connection  with  congenital  malformations  of  the  kidneys,  or  as  a 
result  of  hereditary  syphilis,  tuberculosis,  and  heart  disease. 

In  the  early  stages  of  chronic  nephritis  the  diagnosis  rests  princi- 
pally upon  the  chemic  and  microscopic  findings  in  the  urine.  (See 
p.  574.)  In  parenchymatous  nephritis  the  quantity  of  urine  is  normal 
or  diminished,  the  specific  gravity  normal  or  increased,  the  albumin 
content  high,  and  the  color  cloudy,  brownish  yellow  or  bloody.  In 
interstitial  nephritis  the  quantity  of  urine  is  increased,  the  specific 
gravity  low,  the  albumin  content  low  (occasionally  no  albumin),  and 
the  color  clear,  and  pale.  In  amyloid  degeneration  the  urine  is  rich 
in  serum  albumin  and  globulin.  Its  quantity  is  often  increased.  Casts 
in  the  urine  are  present  in  all  varieties.   " 

Where  laboratory  facilities  are  at  our  command,  it  is  of  great  diag- 


578  .  DISEASES   OF   CHILDREN 

nostic  and  prognostic  advantage  to  determine  the  functional  capacity 
of  the  kidneys  by  means  of  the  phenolsulphonephthalein  test  and  the 
"two-hour"  renal  test. 

With  further  advance  of  the  disease,  the  gradually  appearing  profound 
anemia,  digestive  and  respiratory  disturbances,  local  and  general 
dropsy,  and  cardiac  debility  readily  disclose  the  underlying  condition. 
Toward  the  end  of  life  the  symptoms  resemble  greatly  those  of  non- 
compensating  heart  disease. 

Parenchymatous  nephritis  offers  the  worst  prognosis,  death  usually 
setting  in  within  a  year  from  the  appearance  of  the  secondary  symp- 
toms. The  course  of  interstitial  and  amyloid  nephritis  is  much  more 
protracted,  and  cases  of  amyloid  kidney  are  on  record  that  markedly 
improved  on  removal  of  the  suppurative  bone  affection;  however,  com- 
plete recovery  is  practically  out  of  the  question. 

Treatment. — Under  suitable  treatment  (except  in  parenchymatous 
variety)  life  may  be  prolonged  for  many  years.  As  in  acute  nephritis, 
the  diet  should  be  free  from  salt,  but  otherwise  should  be  more  liberal. 
Older  children  may  live  on  a  mixed  diet;  the  following  foodstuffs, 
however,  are  to  be  exempt  from  the  list:  liver,  ham,  brains,  kidneys, 
beef -juice,  and  beef  extract,  soups,  coffee,  liquors  and  spices.  All  meats, 
eggs  and  fish  should  be  taken  sparingly.  Whenever  possible,  the 
child  should  live  in  a  warm  climate.  Outdoor  life  and  very  ligJit 
exercise  are  desirable.  Daily  warm  baths  with  gentle  massage  act  bene- 
ficially. With  the  appearance  of  dropsy,  dyspnea,  or  other  grave  symp- 
toms, the  patient  should  be  put  to  bed  and  treated  in  the  manner  out- 
lined under  "Acute  Nephritis"  and  "Chronic  Heart  Disease"   (g.  v.). 

Hematinics,  in  small  doses,  and  other  tonics  in  the  form  of  cod 
liver  oil,  nux  vomica,  and  digestants  are  in  order  as  necessity  arises. 
Excessive  dropsical  effusions  should  be  relieved  by  active  catharsis, 
alkaline  diuretics,  and  heart  stimulants  (digitalis,  diuretin),  in  addi- 
tion to  the  therapeutic  measures  recommended  in  dropsy  accompany- 
ing acute  nephritis. 

In  protracted  cases,  considerable  benefit  may  be  derived  from 
Karell's  diet,  which  consists  of  60  to  200  c.c.  of  skimmed  milk  every 
four  hours  during  the  day,  with  exclusion  of  every  other  food  and 
drink.  In  some  cases  protein  milk  may  be  tried.  Splitting  or  extirpa- 
tion of  the  kidney  capsule  (Edebohls'  operation)  will  often  prolong  life. 

Nephrolithiasis 

(Stones  in  the  Kidney,  Eenal  Calculi) 

Kenal  calculi  in  children  give  rise  to  symptoms  identical  with  those 

observed   in   adults.     Thus,   sudden  attacks   of   pain  in  the   lumbar 

fegion,  radiating  downward  along  the  course  of  the  ureters,  groins, 


DISEASES    OF    THE   KIDNEYS   AND   BLADDER 


579 


and,  in  the  male,  to  the  testicles.  The  attacks  are  usually  associated 
with  nausea,  vomiting,  and  sometimes  convulsions  and  collapse.  The 
urine  is  passed  frequently,  in  small  quantities,  and  contains  blood  and 
pus  cells.  The  urine,  however,  may  appear  normal  if  it  is  excreted 
from  the  healthy  kidney  only;  or  there  may  be  complete  anuria  if  both 
ureters  are  simultaneously  obstructed. 

Treatment. — Where  the  stones  remain  impacted  in  the  ureter,  the 


Fig.  167. — Oval  calculus  in  left  ureter  and  one  just  emerging  from  lower  pole  of  left 
kidney  in  a  cliild  nine  years  old. 


580  DISEASES   OF    CHILDREN 

condition  is  apt  to  become  very  grave  in  consequence  of  supervening 
hydronephrosis,  pyonephrosis,  or  pyelonephritis.  In  this  event  we 
are  often  obliged  to  resort  to  surgical  interference.  Otherwise  symp- 
tomatic treatment  usually  suffices  to  effect  marked  improvement  or 
even  a  cure.  Alkalies  (piperazine !)  should  be  administered  in  uric  acid 
concrements;  sodium  phosphate  in  oxalic  acid,  and  citric  acid  and  acetic 
acid  in  phosphatic  concrements.  The  diet  should  be  bland  (avoidance  of 
meat),  and  metabolism  enhanced  by  digestives,  mild  laxatives  (I/2  ounce 
of  Margarita  water  in  hot  water  every  morning),  moderate  exercise, 
hydrotherapy  and  massage.  To  relieve  an  attack  we  resort  to  ano- 
dynes (morphine  and  atrophine  hypodermically  or  a  codeine  suppos- 
itory), hot  baths  and  hot  poultices. 

Right-sided  nephrolithiasis  may  be  mistaken  for  acute  appendicitis. 
But  in  addition  to  the  pathognomonic  signs  of  appendicitis  it  will 
generally  be  found  that  the  patient  suffering  from  appendicitis  keeps 
perfectly  still  in  bed  during  the  acute  stage  of  the  attack,  whereas,  the 
nephrolithiasis  patient  is  quite  active,  moving  from  place  to  place  while 
the  pain  is  most  severe. 

An  x-ray  examination  is  often  decisive  in  the  diagnosis  between 
nephrolithiasis  and  appendicitis.  In  older  children  cystoscopy  will 
greatly  aid  in  the  diagnosis.     (See  "Uric  Acid  Infarcts".) 

Pyelitis,*  Pyelonephritis,  Pyelonephrosis 

Inflammation  of  the  pelvis  of  the  kidney  and  contiguous  structures 
with  consecutive  suppuration  usually  occurs,  as  first  demonstrated  by 
Escherich,  as  a  result  of  infection  by  the  Bacillus  coli  communis  (either 
secondarily  to  enteric  infection,  or  by  systemic  infection  through  some 
lesion  in  the  intestinal  mucosa)  ;  as  a  sequel  of  infectious  diseases, 
such  as  scarlatina,  diphtheria,  variola,  or  pyemia,  or  by  extension  of 
a  suppurative  process  from  the  neighboring  tissues  or  organs,  e.  g., 
perinephritic  abscess,  cystitis,  colicystitis,  (q.v),  purulent  vulvo- 
vaginitis and  also  as  a  result  of  direct  injury  to  the  lining  mucous  mem- 
brane, e.  g.,  renal  stones.  It  is  also  met  with  in  connection  with  con- 
genital malformations  of  the  kidneys  or  ureters,  renal  tuberculosis  and 
tumors.  The  pyelitis  may  be  unilateral  (when  due  to  a  local  cause)  or 
bilateral. 

The  symptomatology  of  pyelitis  varies  greatly  with  the  cause  and 
the  course  it  pursues.  In  acute  cases  there  are  rigors,  high  and  fluc- 
tuating temperatures,  frequent  and  scanty  urination,  pain  in  the  lum- 
bar region  (often  elicited  also  on  palpation)  and,  above  all,  pyuria. 
The  morphologic  constituents  of  the  urine  vary  with  the  degree  of 


*See  also  Pyelocystitis. 


DISEASES    OF    THE    KIDNEYS    AND    BLADDER  581 

involvement  of  the  kidneys,  ureters  and  bladder.  In  a  large  number  of 
cases  the  pyelitis  is  masked  by  the  primary  affection  and  can  only  be 
detected  by  examination  of  the  urine — which  should  invariably  be 
done  where  irregular,  high  fever,  without  apparent  cause,  prevails. 
Cases  pursuing  a  chronic  course  are  ordinarily  free  from  febrile  ex- 
cursions, but  the  children  are  pale  or  waxy  in  color,  complain  of  head- 
ache, lassitude  or  cardiac  palpitation  and  other  symptoms  of  wasting 
diseases.  Pj^onephritis  with  pus  retention  (pyonephrosis)  often  gives 
rise  to  a  palpable  tumor. 

"Where  the  cause  is  removable,  and  prompt  treatment  is  instituted, 
the  pyelitis  may  entirely  disappear  and  leave  the  kidney  uninjured. 
Otherwise  the  prognosis,  as  to  complete  recovery,  is  bad.  The  prog- 
nosis as  to  life  depends  entirely  upon  the  exciting  cause  and  compli- 
cations, nephritis  and  exhaustion  forming  the  principal  sources  of 
danger. 

Treatment. — The  aim  of  the  treatment,  therefore,  should  be  to  avoid 
nephritis  by  early  elimination  of  the  fundamental  disease,  and  pre- 
vention of  recurrences  of  the  attacks.  The  details  of  such  treatment  are 
fully  outlined  when  speaking  of  the  disease  in  question.  Otherwise 
the  treatment  is  symptomatic.  Rest  in  bed  and  liquid  diet  during  the 
acute  course  of  the  disease.  Urotropin,  from  3  to  5  grains  every  four 
hours,  is  indicated  in  all  cases.  The  urine  should  be  rendered  alkaline 
and  as  aseptic  as  possible.  This  is  best  accomplished  by  a  liberal  supply 
of  water,  alkaline  diuretics  such  as  potassium  citrate  {gr.  x  t.  i.  d.)  in 
addition  to  the  hexamethylenamine.  Of  late  attempts  have  been  made 
to  cure  chronic  pyelitis  by  irrigating  and  draining  the  renal  pelvis. 
Kretschmer*  and  Helmholz  claim  to  have  cured  a  number  of  cases  of 
pyelitis  by  injecting  into  the  renal  pelvis  1  c.c.  to  5  e.c.  of  a  0.5  per  cent 
of  silver  nitrate  solution.  The  injections  may  be  repeated  once  or  twice, 
until  the  urine  cultures  become  sterile.  The  results  as  a  whole  are  not 
very  encouraging.  The  same  is  true  of  the  administration  of  vaccines. 
Pyonephrosis  calls  for  surgical  interference.  (See  also  ''Pyelocysti- 
tis".) 

Hemoglobinuria 

Hemoglobin  or  methemoglobin  in  the  urine  is  occasionally  observed 
in  infants  and  older  children,  either  as  a  result  of  poisoning  by  phos- 
phorus, potassium  chlorate,  carbolic  acid,  etc.,  or  in  connection  with 
severe  burns,  acute  and  chronic  infectious  diseases,  such  as  exanthe- 
mata, malaria,  and  hereditary  syphilis.  The  urine  is  mahogany- 
brown  or  black  in  color,  greatly  resembling  bloody  urine.  Micro- 
scopically, however,  it  shows  the  presence  of  blood  coloring  substance 


*Jour.  Am.   Med.   Assn.,   Nov.    13,    1920. 


582  DISEASES   OF    CHILDREN 

only,  but  no  blood  corpuscles.  The  spectroscope  discloses  bands  of 
hemoglobin.  The  attacks  of  the  hemoglobinuria  are  of  brief  duration 
(sometimes  last  but  a  few  hours),  and  are  manifested  by  debility, 
chilliness,  cyanosis,  and  sometimes  high  fever.  These  symptoms  dis- 
appear as  the  urine  clears  up,  which  ordinarily  occurs  within  a  few 
hours  or  days.  Occasionally  the  hemoglobinuria  appears  in  parox- 
ysms (paroxysmal  henioglohinuria)  without  any  discernible  cause  or 
after  exposure  to  cold  or  undue  fatigue. 

By  rest  in  bed,  liberal  supply  of  liquids,  and  attention  to  the  excit- 
ing cause,  the  hemoglobinuria  subsides  without  any  serious  conse- 
quences.    (See  "Epidemic  Hemoglobinuria".) 

Orthotic,  Lordotic,  Cyclic  or  Functional  Albuminuria 

As  the  term  (orthotic:  standing  up)  indicates,  the  disease  is 
characterized  by  the  presence  of  albuminuria  after  the  patient  has 
been  up  and  around  (usually  several  minutes  after  the  erect  posture 
has  been  assumed)  and  by  its  absence  while  he  is  perfectly  at  rest. 
It  is  observed  especially  in  delicate  children  of  from  five  to  fifteen 
years  of  age,  and  seems  to  have  nothing  in  common  with  organic 
kidney  disease.  It  has  been  observed  that  children  suffering  from 
lordosis  in  the  upper  lumbar  spine  are  especially  prone  to  be  affected 
by  the  disease — the  spinal  deformity  by  pressure  upon  the  kidneys  ap- 
parently interfering  with  the  renal  circulation.  A  family  predisposi- 
tion has  been  traced  in  some  cases,  and  a  history  of  scarlatina  and 
diphtheria  in  others.  The  urine  is  ordinarily  free  from  abnormal 
morphologic  constituents,  the  opposite,  of  course,  being  the  case  in 
true  renal  disease. 

Treatment. — Under  suitable  treatment,  which  is  essentially  the  same 
as  in  the  early  stage  of  chronic  nephritis  plus  correction  of  lordosis, 
if  there  be  any,  the  albuminuria  often  disappears  for  a  time,  but  may 
return  after  a  shorter  or  longer  interval  (intermittent  form).  Not- 
withstanding the  continuance  of  the  albuminuria  for  many  years,  the 
system  is  very  little  affected  by  it,  and  the  prognosis  as  to  life  is  good. 
Transition  of  cyclic  albuminuria  into  nephritis,  however,  is  on  record. 

Tumors  of  the  Kidney 

Aside  from  tuberculosis  and  syphilis,  which  have  been  discussed 
elsewhere,  the  kidneys  are  occasionally  the  seat  also  of  benign  and 
malignant  neoplasms.  The  benign  tumors  (adenoma,  fibroma  lipoma, 
cysts,  etc.)  owing  to  their  very  slow  growth,  generally  escape  observa- 
tion, and  are  often  found  postmortem  in  children  who  during  life  never 


DISEASES    OF    THE   KIDNEYS   AND   BLADDER 


583 


manifested  signs  of  kidney  growths.  To  a  great  extent  this  is  true 
also  of  malignant  tumors  (sarcoma,  carcinoma,  myosarcoma,  and  ad- 
enosarcoma)  in  their  early  stages  of  development,  since  at  this  period 
the  tumor  is  barely  palpable,  and  the  two  additional  characteristic 
signs  of  malignant  kidney  growths  {i.  e.  hematuria  and  cachexia)  are 
present  only  in  a  small  percentage  of  such  cases  (usually  carcinoma) 
and  are  encountered  also  in  a  number  of  other  wasting  and  hemorrhagic 
diseases.  Moreover,  hematuria  is  often  absent  during  the  late  stage, 
when  the  tumor  encroaches  upon  the  ureter  and  obstructs  the  flow  of 
urine  from  the  affected  kidney.  Ascites  is  a  frequent  symptom,  and 
the  colon  is  usually  pushed  in  front  of  the  tumor.    As  the  growth  ad- 


Fig.  168. — Adcnosarcoma  of  right  kidney  in  a  boy  twenty-seven  montlis  old,  occupy- 
ing almost  the  entire  abdomen. 


vances  it  spreads  in  all  directions  displacing  the  liver,  spleen,  heart 
and  lungs,  and  occupies  the  entire  abdominal  cavity.  Not  rarely, 
secondary  metastases  are  formed  in  the  other  kidney,  in  the  liver, 
spleen,  intestines  and  retroperitoneal  glands,  and  by  pressure  upon 
the  ureter,  give  rise  to  hydronephrosis.  Roentgen-ray  examination  is 
helpful  in  the  diagnosis. 

Treatment. — Unless  operated  upon  early — which  treatment  should 
invariably  be  recommended — the  children  usually  succumb  to  pro- 
gressive emaciation  and  exhaustion  within  about  a  year  from  the  time 
the  tumoB  makes  itself  felt.  As  the  majority  of  the  growths  are  of 
antenatal  origin,  nothing  can  be  done  in  the  way  of  prophylaxis. 


584  DISEASES    OF    CHILDREN 

Cystitis,  Colicystitis 
(Pyelocystitis) 

Inflammation  of  the  bladder  may  occur  as  a  primary  or  secondary 
disease.  Primary  cystitis  is  extremely  rare  in  children,  more  especially 
in  infants,  since  the  principal  cause — direct  mechanical  injury  of  the 
mucous  membrane  by  surgical  instruments  or  other  foreign  bodies — is 
but  rarely  operative  in  young  children.  On  the  other  hand,  secondary 
cystitis  is  of  comparatively  frequent  occurrence,  more  particularly  in 
girls,  and  may  arise  from  a  great  many  causes,  the  most  important  be- 
ing infectious  diseases  (diphtheria,  scarlatina,  etc.),  kidney  and  blad- 
der disease  (calculi,  pyelitis,  tuberculosis,  tumors,  etc.),  cerebrospinal 
affections  (atony  and  overdistension  of  the  bladder  with  consecutive 
inflammation  by  decomposed  urine),  intestinal  diseases  (invasion  of  the 
bladder  by  the  colon  bacillus — {Colicystitis),  and  diseases  of  the  vagina 
and  urethra,  especially  of  gonorrheal  origin  (by  extension  of  the 
inflammation).  Cystitis  may  follow  chemical  irritation  (from  over- 
doses of  cantharides,  balsams,  liquors,  etc.),  exposure  to  cold  (sitting 
on  cold  stones,  etc.),  and  direct  external  violence. 

The  lesions  in  the  bladder  may  range  from  simple  localized  redness 
to  extensive  ulceration  of  the  mucous  membrane  and  pseudomem- 
branous deposit.  In  cases  of  long  standing  the  inflammation  is  prone 
to  spread  to  the  ureters  and  kidneys.  In  chronic  cystitis  the  mucosa 
assumes  a  gray,  pigmented  color,  becomes  greatly  hypertrophied, 
and  is  covered  by  mucopurulent  masses. 

In  accord  with  the  severity  and  extent  of  the  lesion  cystitis  may  be 
manifested  by  mild  or  grave  symptoms.  The  latter  are  most  pro- 
nounced in  primary  cases,  in  those  associated  with  infectious  dis- 
eases (e.  g.,  diphtheria),  and  in  infection  by  the  colon  bacillus.  In  mild 
cases  the  symptomatology  consists  of  painful  and  frequent  micturi- 
tion, sensitiveness  over  the  region  of  the  bladder,  sometimes  rectal 
tenesmus  and  excoriation  of  the  urethral  orifice  and  of  the  contiguous 
structures.  The  urine  is  voided  in  small  quantities,  sometimes  only 
a  few  drops  at  a  time,  and  contains  mucous  shreds,  bladder  epithe- 
lium, pus  corpuscles,  blood  corpuscles,  and  numerous  bacteria.  The 
urine  in  simple  cystitis  is  neutral  or  alkaline,  cloudy  and  dark  red, 
and  may  contain  pieces  of  membrane,  if  the  cystitis  is  of  diphtheritic 
origin.  On  the  other  hand,  in  colicystitis  the  urine  is  acid  in  reaction, 
and  in  addition  to  the  aforementioned  constituents  we  find  a  large  quan- 
tity of  pus  and  some  albumin,  and,  not  rarely,  there  are  marked  con- 
stitutional disturbances,  such  as  vomiting,  chills,  irregular  fever,  and 
sometimes    convulsions    (particularly    if    anuria    exists).      The    local 


DISEASES    OF    THE    KIDNEYS    AND    BLADDER  585 

S3'mptoms  also  are  niucli  more  pronounced.  If  left  to  run  its  course, 
the  condition  is  not  rarely  aggravated  by  the  concurrence  of  nephritis 
and  pyelonephritis  (q.v.)  which  maj"  lead  to  fatal  termination. 

Treatment. — As  it  is  not  always  possible  in  the  beginning  to  foresee 
the  eventual  course  of  the  disease,  and  as  the  tendency  even  of  mild 
cases  toward  chronicity  is  great,  it  is  essential  not  to  trifle  with  the 
affection,  but  promptly  to  employ  all  such  therapeutic  measures  as 
will  insure  its  early  arrest  and  ultimate  cure.  The  patient  should  be 
put  to  bed  and  on  a  mild  diet  (milk  and  Vichy  water,  milk  gruel, 
fermented  milk,  and  well-boiled  vegetables).  All  spices,  alcoholic 
beverages,  coffee,  and  tea  should  be  prohibited.  To  relieve  pain, 
hyoscyamus  is  the  remedy  par  excellence.  It  may  be  combined  with 
citrate  or  acetate  of  potash  and  small  doses  (3  grains  every  four  hours) 
of  hexamethylenamine.  Warm  Priessnitz  compresses  are  also  of  value. 
Where  the  pain  persists,  a  suppository  of  codeine  and  extract  of 
belladonna  will  be  found  to  act  well.  With  subsidence  of  the  acute 
symptoms — usually  after  a  week  or  two — it  is  advisable  to  begin  to 
irrigate  the  bladder  (under  the  most  careful  aseptic  precautions)  with 
a  warm  solution  of  boracic  acid  (5  i  to  0  i)  or  of  nitrate  of  silver  or 
potassium  permanganate  (1/2000  or  1/1000).  From  I/2  pint  to  1  quart 
of  the  solution  may  be  used  for  each  treatment,  and  the  irrigation  may 
be  repeated  once  a  day  or  every  other  day.  In  mild  cases  boric  acid 
solution  (1  dram  to  1  quart)  alone  may  suffice. 

Under  this  method  of  treatment  the  majority  of  cases  of  cystitis 
will  recover  in  from  four  to  eight  weeks;  provided,  of  course,  the 
primary  cause  can  be  detected  and  removed. 

Transition  of  simple  acute  cystitis  into  chronic  is  by  far  less  com- 
mon in  children  than  in  adults.  The  possibility  of  the  disease  being 
tubercular  in  nature,  however,  should  always  be  borne  in  mind.  (See 
p.  457.)  For  diagnostic  purposes  F.  Hinman  (Am.  Jour.  Dis.  Child., 
May,  1919)  strongly  advocates  cystoscopy  and  ureteral  catheteriza- 
tion in  all  chronic  cases,  irrespective  of  sex  or  age  of  the  child. 


Potassii  Acetatis 

3i 

4.00 

Ext.   Hyoscyami   Fl. 

m.  xvi 

1.00 

Ext.  Tritici  Repens  FI. 

3i 

4.00 

Inf.  Uva3  Ursi 
M. 

S. — One  tcaspoonful  in 

q.  s.  ad  5  ii 

60.00 

water  every  four  hours, 

for  a  child  five  years  old 

(Simple  cysti 

tis.) 

In  subacute  or  chronic  colieystitis  or  pyelocystitis,  urotropin  is  the 
remedy  of  choice.  It  acts  best  in  combination  with  potassium  citrate, 
5  grains  of  each  every  4  hours.    In  refractory  cases  we  may  have  to 


586  DISEASES   OF    CHILDREN 

resort  to  frequent  irrigations  of  the  bladder  and  even  of  the  ureters. 
Chronic  cases  will  often  yield  to  these  procedures  alone  or  in  conjunc- 
tion with  biweekly  hypodermic  injections  of  autogenous  vaccine.  (See 
''Pyelitis".) 

Vesical  Calculi 

(Stones  in  the  Bladder) 

Bladder  stones  sooner  or  later  give  rise  to  the  following  character- 
istic symptom  complex :  Vesical  and  often  rectal  tenesmus,  strangury, 
partial  or  complete  retention  or  incontinence  of  urine,  difference  in 
the  force  of  the  stream  of  urine  with  change  in  posture  of  the  patient, 
and,  after  a  protracted  course,  the  usual  symptoms  of  cystitis  {q.  v.). 
The  urine  may  reveal  the  presence  of  either  phosphate  stones  (phos- 
phate and  carbonate  of  lime,  magnesia),  oxalate  stones  (oxalate  of 
lime),  or  urate  stones  (uric  acid).  Small  eoncrements  may  escape 
with  the  urine;  large  ones,  however,  are  apt  to  become  impacted  in 
the  urinary  canal  and  cause  intense  pain  and  grave  nervous  symp- 
toms, e.  g.,  convulsions. 

The  diagnosis  is  based  upon  the  aforementioned  manifestations, 
upon  feeling  the  stone  in  the  bladder  by  rectal  digital  examination  or 
by  a  sound  introduced  into  the  bladder,  and  upon  an  x-ray  examina- 
tion. 

The  development  of  stones  may  frequently  be  prevented  by  a  bland 
diet  (no  meats),  ample  supply  of  water,  and  attention  to  the  bowels. 
In  cases  of  long  standing  operative  interference  is  indispensable. 
Painful  symptoms  are  relieved  by  means  of  hyoscyamus,  or  opium  and 
belladonna  suppositories. 

Spasmus  Vesicae,  Dysuria,  Ischuria 

(Anuria) 

These  conditions  are  etiologically  correlated.  In  the  majority  of 
instances  they  are  the  result  of  vesical  calculi,  blood  clots  obstructing 
the  urinary  flow,  phimosis,  paraphimosis,  vulvitis  and  vaginitis,  cys 
titis,  uric  acid  infarcts  (in  the  newborn),  sudden  chilling  of  and  in- 
jury to  the  lower  portion  of  the  abdomen,  nerve  affections  (functional 
or  organic),  and  priapism  (in  the  male). 

Treatment. — The  treatment  varies  with  the  original  cause.  An  at- 
tack is  usually  relieved  by  a  hot  bath,  a  suppository  of  codeine  and 
extract  of  belladonna,  and  the  administration  of  diuretics,  such  as 
sweet  spirits  of  niter  and  extract,  triticum  repens. 


DISEASES   OF    THE   KIDXEYS    AND   BLADDER  587 


I^ 


Potassii  Citriitis 

31 

4.00 

Ext.  Hyoseyami  Fl. 

m.  xxi 

1.00 

Ext.  Tritiei  Repens  Fl. 

3i 

4.00 

Syr.   Simplicis 

3  iv 

15.00 

Aq.  Anisi 

q.  s 

.  ad  5  ii 

GO.OO 

M. 

S. — One    tcaspoonful 

in 

wa 

tcr    every    three 

hours,  for  a  child  three 

years 

old. 

Enuresis 
(Bed-wetting.     Incontinence  of  Urine.) 

It  is  customary  to  distinguish  two  varieties  of  enuresis  in  children: 
enuresis  diurna  and  enuresis  nocturna.  The  first  variety  is  but  rarely 
met  with  in  children,  capable  of  differentiating  right  from  wrong,  ex- 
cepting in  those  who  willfully  "wet"  themselves,  or  in  congenital 
deficiencies  (spina  bifida,  q.  v.).  The  second  variety,  on  the  other  hand, 
occurs  in  a  very  great  number  of  children,  regardless  of  age,  sex,  in- 
telligence or  social  conditions.  The  child  may  wet  the  bed  one  or 
more  times  every  night,  or  at  intervals  of  days  or  weeks;  in  the  last 
event,  it  is  usually  due  to  willfulness,  excessive  drinking,  or  faulty 
diet.  An  inherited  tendency  and  neurotic  disposition  seem  to  play  an 
important  part  in  the  causation  of  enuresis,  although  the  latter  may 
exist  independently  of  either  of  these  causes  in  children  apparently 
perfectly  healthy. 

The  causes  of  enuresis  may  conveniently  be  arranged  in  two  classes : 

1.  Functional. — The  cases  due  to  functional  causes  are  purely  neu- 
rotic in  character.  The  urine  is  voided  involuntarily  either  owing  to 
atony  of  the  sphincter  vesicae,  or  to  a  spasmodic  condition  of  the  detrusors 
vesicae.  In  both  cases  there  is  a  functional  disturbance  in  the  nervous 
apparatus  of  the  urinary  system.  It  is  usually  found  that  enuresis  due 
to  atony  is  associated  with  general  debility,  and  often  follows  a  pro- 
tracted course  of  an  exhausting  disease.  On  the  other  hand,  enuresis 
due  to  "spasm"  is  usually  found  in  children  who  are  irritable,  who 
present  an  increased  patellar  reflex,  are  easily  frightened,  are  subject 
to  pavor  nocturnus  and  similar  nervous  conditions. 

2.  Organic. — A  great  many  cases  arise  from  organic  troubles. 
The  child  may  suffer  from  organic  disease  of  the  spinal  cord  (spina 
bifida);  cystitis;  phimosis  or  paraphimosis  (in  the  male)  ;  hypertrophy 
of  the  clitoris  or  adhesion  of  the  prepuce  (in  the  female)  ;  masturba- 
tion ;  undescended  testicle ;  hernia,  worms ;  vesical  and  renal  calculi ; 
tumors  in  the  bladder;  excessive  quantity  of  lithiates  or  phosphates; 
constipation  and  accumulation  of  feces  in  the  rectum ;  epi-  or  hypo- 
spadias; fissura  ani;  vulvovaginitis;  diabetes,  gonorrhea,  simple  or 
gonorrheal  proctitis.     Finally  it  may  here  be  mentioned  that  hyper- 


588  DISEASES   OF   CHILDREN 

trophied  tonsils  and  adenoids  may  be  responsible  for  intractable  enu- 
resis. 

Treatment.- — In  the  treatment  of  enuresis  it  is  of  greatest  moment 
to  systematically  examine  the  patients  for  the  organic  diseases  just 
enumerated  and  to  endeavor  to  eliminate  every  symptom  suspicious 
of  organic  disease.  In  absence  of  organic  causes  there  is  evidently  a 
neurotic  case  to  be  dealt  with  and  the  treatment  must  be  adopted  ac- 
cordingly. The  patient  if  old  enough  should  be  instructed  not  to  ab- 
stain from  micturition  when  called  upon  by  nature  to  do  so,  and  small 
children  should  be  trained  to  void  urine  every  three  hours,  and  not  be 
permitted  to  withhold  the  urine  for  a  longer  period.  This  is  very  im- 
portant, for  it  is  often  overdistention  of,  and  decomposition  of  the 
urine  in,  the  bladder  that  prove  the  primary  cause  of  the  subsequent 
secondary  etiologic  factors,  (atony  or  hyperesthesia  of  the  bladder, 
presence  of  concretions,  cystitis,  etc.).  It  is  also  advisable  to  en- 
courage drinking  of  water  in  cases  of  enuresis  due  to  concretions, 
cystitis,  or  gonorrhea,  but  to  forbid  it  in  other  cases.  The  patient 
is  not  to  be  permitted  to  sleep  on  his  back,  and  it  is  often  of  advantage 
to  raise  the  foot  of  the  bed  in  such  a  manner  that  the  child's  trunk 
and  head  lie  deeper  than  the  pelvis. 

In  enuresis  due  to  ato7iy  a  general  constructive  treatment  is  indi- 
cated. Plenty  of  good  nourishment,  change  of  air,  cold  spinal  douches, 
medicinal  tonics  and  electricity  are  usually  effective  in  bringing  about 
a  cure.  A  moderate  galvanic  current  is  usually  best ;  one  pole  is  applied 
to  the  symphysis  or  sacrum,  the  other  to  the  perineum.  The  following 
mixture  is  often  very  serviceable : 


Ext. 

Ergotae  Fl. 

3  iii 

12.00 

Ext. 

Ehus  Toxieonclron 

3i 

4.00 

M. 

1 

S. 

— Five  to  10  drops 

every 

four  to 

six 

hours, 

for 

a  child  six  years  old. 

In  incontinence  of  urine  associated  with  hyperesthesia  of  the  collum 
vesicas  or  spasm  of  the  detrusors,  antispasmodic  treatment  is  indi- 
cated, consisting  of  hot  sitz-baths,  avoidance  of  irritating  food  or  drinks 
and  the  administration  of  either  extract  of  belladonna  or  hyoscyamus. 
I  usually  prescribe  the  following: 


Ext.   Hyoscyami  Fl.                            3  ss 

2.00 

Natrii  Bromidi                                         3  i 

4.00 

Syr.  Simplicis                                          5  i 

30.00 

Aq.  Anisi                                q.  s.  ad  5  ii 

60.00 

M. 

S. — One  teaspoonful  in  water,  three 

;imes  a 

day,  for  a  child  eight  years  old. 

DISEASES    OF    THE   KIDNEYS   AND   BLADDER  589 

Counterirritation  by  moans  of  sinapisms  over  the  lumbosacral  region 
often  does  well,  and  if  everythin*?  fails,  this  class  of  cases  is  occasion- 
ally cured  by  gradual  dilatation  of  the  i:»osterior  uretliral  canal. 

More  recently  some  benefit  has  been  claimed  from  the  administration 
of  pituitrin,  in  5  drop  doses  (placed  under  the  tongue  or  hypodermic- 
ally)  three  times  a  day. 

As  to  the  treatment  of  enuresis  from  organic  causes,  nothing  more 
will  be  said  here  than  that  each  case  must  be  treated  as  an  individual  dis- 
ease in  accordance  with  its  etiology. 

Remonstrance,  severity  and  moral  suasion  will  often  cure  cases  of 
enuresis  of  nervous  origin  or  those  which  continue  from  mere  habit 
long  after  removal  of  the  original  cause. 

Vulvovaginitis 

(Cervicitis) 

Clinically  vulvovaginitis  may  be  classified  as  follows: 

1.  Catarrhal  vulvovaginitis,  which  is  generally  due  to  (a)  lack  of 
cleanliness  or  (&)  chemical  irritation. 

2.  Traumatic  vulvovaginitis,  which  is  due  to  (a)  masturbation  (?), 
(&)  mechanical  injury,  or  (c)  indecent  violence. 

3.  Parasitic  vulvovaginitis,  which  is  due  to  (a)  oxyurides,  (&) 
saprophytes,  or  (c)  pathogenic  bacteria,  especially  the  gonococcus. 

The  first  variety  of  vulvovaginitis  is  usually  met  in  poorly  nour- 
ished children  of  overcrowded  tenement  districts,  who  receive  a  thor- 
ough cleansing  on  very  special  occasions  only.  As  a  rule,  these  cases 
begin  with  vulvitis,  the  vagina  becoming  gradually  involved  by  ex- 
tension of  the  inflammation.  Catarrhal  vulvovaginitis  is  not  always 
limited  to  the  very  poor,  and  the  physician  need  not  hesitate  to  sus- 
pect dirt  even  under  the  most  elaborate  apparel. 

This  variety  of  vulvovaginitis  is  also  frequently  observed  in  children 
whose  genitalia  are  exposed  to  excessive  wetting  by  irritating,  de- 
composing secretions,  and  excretions — sweat,  diarrheal  stools,  hyper- 
acid urine — and  to  undue  pressure  and  friction.  In  former  years, 
when  bicycle  riding  Avas  a  national  fad,  vulvovaginitis  was  not  rarely 
met  with  in  assiduous  bicycle  riders,  undoubtedly  as  a  result  of  the 
aforesaid  causes.  To  the  catarrhal  type  belongs  also  the  vaginitis 
occasionally  observed  in  the  newborn. 

The  consideration  of  the  second,  traumatic,  variety  of  vulvovagini- 
tis does  not,  strictly  speaking,  belong  to  the  domain  of  medicine, 
except  as.  regards  the  treatment.  "We  are  dealing  here  with  faulty 
habits  and  criminal  traits  which  deserve  serious  attention  on  the  part 


590  DISEASES   OP   CHILDREN 

of  teachers,  the  clergy,  and  jurists.  However,  as  it  is  the  physician 
who  is  usually  consulted  first,  a  few  points  of  information  will  prove 
useful  to  him,  particularly  as  a  warning  not  to  be  too  hasty  in  ex- 
pressing a  positive  opinion. 

I  believe  that  entirely  too  much  stress  is  being  laid  by  some  authors 
upon  masturbation  as  an  etiologic  factor  of  vulvovaginitis.  It  is  much 
more  probable  that  masturbation  is  a  result  rather  than  a  cause  of  it, 
the  undoubtedly  existing  irritated  state  of  the  erectile  tissue  inducing 
that  bad  habit. 

The  presence  of  foreign  bodies  in  the  vagina  is  not  infrequently 
found  to  be  the  cause  of  vulvovaginitis.  While  some  girls  will  intro- 
duce foreign  bodies  in  the  vagina  with  lascivious  intent,  the  great 
majority  of  foreign  bodies,  {e.g.,  safety  pins),  will  find  their  way  in 
the  vaginal  canal  accidentally,  and  should  always  be  looked  for,  par- 
ticularly in  cases  of  long  standing. 

Occasionally  cases  of  vulvovaginitis  are  encountered  which  are  the 
result  of  indecent  violence.  The  purulent  discharge  is  either  non- 
gonorrheal  or  gonorrheal,  the  latter  only  if  the  criminal  who  at- 
tempted rape  had  at  the  time  been  suffering  from  gonorrhea.  It  is 
well  to  remember  that  not  every  case  of  vulvovaginitis  reported  as 
due  to  rape,  is  really  such,  and  unless  the  vaginitis  is  associated  with 
actual  penetration  of  the  hymen  and  concomitant  signs  of  inflamma- 
tion due  to  violence,  the  physician  should  be  very  cautious  in  ventur- 
ing a  positive  opinion. 

Saprophytic  microorganisms  are  responsible  for  a  great  number 
of  cases  of  vaginitis.  To  them  is  attributable  the  vaginitis  not  in- 
frequently met  with  after  acute  exanthematous  diseases  (e,  g.,  measles 
and  scarlet  fever)  and  in  conjunction  with  divers  forms  of  cutaneous 
eruptions.  The  same  cause  accounts  also  for  the  vaginitis  observed 
in  strumous  and  debilitated  children  suffering  from  purulent  dis- 
charges from  the  nose,  ears,  etc. — the  discharges  being  carried  to 
the  vagina.  Indeed,  the  number  of  cases  of  saprophytic  vulvo- 
vaginitis would  by  far  exceed  all  those  arising  from  all  other  sources 
collectively  were  it  not  for  the  antagonistic  action  of  the  bacillus  of 
Doderlein  which  normally  inhabits  the  vagina.  This  vagina  bacillus, 
which  is  anaerobic  and  may  be  cultivated  on  ordinary  media,  produces 
lactic  acid  during  its  growth,  a  quality  to  which  is  due  the  presence 
of  lactic  acid  in  the  healthy  vagina.  In  its  presence  saprophytes,  as 
well  as  numerous  other  bacteria,  such  as  the  staphylococcus  and 
streptococcus,  are  unable  to  develop,  and  within  a  short  time  perish. 
Gonococci,  however,  do  not  yield  as  promptly  to  the  destructive  effect 
of  the  vagina  bacillus;  hence,  the  frequency  with  which  gonorrheal 


DISEASES   OF    THE   KIDNEYS   AND   BLADDER  591 

vulvovaginitis  is  met,  notwitlistaiiding  the  resistance  offered  to  the 
entrance  of  gonococci  into  the  vagina  by  the  stratified  sqiiamons 
epithelium  lining  it. 

As  stated  before,  contamination  of  the  vagina  by  criminal  assault 
is  comparatively  very  rare.  Much  more  frequently,  infection  takes 
place  by  voluntary  sexual  act  or  accidentally.  Little  girls  sleeping 
with  their  parents,  elder  brothers,  sisters,  or  nurses  suffering  from 
gonorrhea,  may  contract  the  disease  by  coming  in  contact  with  soiled 
bed  clothes,  cotton  pads,  or  other  articles  used  for  cleansing  purposes. 

Gonorrheal  vulvovaginitis  runs  a  more  or  less  virulent  course,  and 
in  hospitals  and  asylums  where  many  children  are  congregated  in 
comparatively  close  quarters,  and  frequently  make  common  use  of  in- 
fected bath  tubs,  toilets,  etc.,  the  disease  is  very  apt  to  become  epi- 
demic as  well  as  endemic.  In  one  epidemic  under  my  care  in  an 
orj^han  asylum,  comprising  over  100  cases,  it  required  many  months 
of  very  active  treatment  to  eradicate  the  affection.  Arrest  of  further 
spread  of  the  gonorrhea  was  not  effected  until  every  patient  was 
isolated  and  kept  in  bed  for  several  weeks.  A  biweekly  examination 
of  every  female  inmate  of  the  institution  (including  the  nurses  in 
charge)  for  vaginal  discharge  was  continued  for  several  weeks  after 
disappearance  of  the  last  case  of  vaginitis. 

Such  procedures  form  the  main  prophylactic  measures  against  the 
disease.  Of  course,  the  patients  must  be  restricted  from  the  common 
use  of  chambers,  bedding,  bath  tubs,  etc.  In  hospitals  and  asylums, 
admitting  physicians  should  be  particularly  careful  to  exclude  all 
children  having  a  purulent  vaginal  discharge,  unless  provision  be 
made  for  the  isolation  and  treatment  of  such  cases.  This  point  is  well 
worthy  of  consideration,  since  it  would  greatly  aid  in  checking  further 
transportation  of  the  disaese.  As  the  majority  of  cases  of  vulvova- 
ginitis are  observed  among  school  children,  a  suggestion  to  the  health 
authorities  is,  perhaps,  in  order,  namely,  to  instruct  the  school  inspec- 
tors to  pay  more  attention  to  the  detection  and  isolation  of  the  cases 
of  gonorrhea  in  children  than  they  usually  do. 

Like  gonorrhea  in  adults,  that  of  children  presents  a  marked 
tendency  toward  grave  complications.  Among  148  cases  under  my 
care,  the  following  serious  complications  were  observed:  purulent 
ophthalmia,  7;  local  peritonitis,  4;  proctitis,  3;  arthritis,  4;  adenitis, 
12.  Several  cases  of  cervicitis,*  endometritis  and  pyosalpinx;  endo- 
carditis, and  pleuritis  are  on  record.    However,  the  more  familiar  one 


*Hess  reports  that  in  4  infants  suffering  from  vaginitis  he  found  (postmortem)  an  inflam- 
mation of  the<  cervix  with  round-cell  infiltration  of  its  submucous  tissue,  and  concludes  that  the 
average  gonococcus  infection  involves  the  cervix  rather  than  the  vagina  ("Gynoplastic  Tech- 
nology,"  by    Dr.   A.    Sturmdorf,    1919). 


592  DISEASES  OF   CHILDREN 

becomes  with  the  course  of  tlie  disease  and  the  l)est  means  of  check- 
ing and  eradicating  it,  the  less  nnmeroiis  will  l)eeome  the  complica- 
tions and  sequelas  in  his  new  cases. 

After  extensive  experimenting  I  found  that  gonorrheal  oph- 
thalmia can  best  be  prevented  by  frequent  cleansing  of  the  geni- 
talia and  hands  of  the  patients,  and  by  the  employment  of  a  large, 
tightly  fitting  vulvar  pad.  The  latter  should  be  changed  for  a  clean 
one  at  least  every  three  hours.  The  child  should  Avear  one-piece  night 
drawers  during  the  night  as  well  as  during  the  day.  The  ophthalmia  may 
sometimes  be  arrested  in  its  incipiency — I  succeeded  in  two  cases— by  in- 
stillation of  silver  solutions  after  Crede's  method.  In  view  of  the 
unusually  rapid  progress  of  the  ophthalmia,  unfortunately,  it  is  not 
often  that  the  physician  has  the  opportunity  to  resort  to  the  pro- 
phylactic measures,  and  nothing  else  remains  but  to  treat  the  disease 
actively  and  skillfully  (see  "Ophthalmia  Neonatorum"),  and,  if  not 
already  involved,  to  endeavor  to  save  the  other  eye  from  the  dreadful 
infection. 

Involvement  of  the  cervix  and  fundus  of  the  uterus  and  adnexa, 
secondarily  to  gonorrheal  vulvovaginitis,  results  in  most  instances 
from  injudicious  use  of  douches  by  forcing  the  vaginal  discharge  up- 
ward into  the  uterus.  Fallopian  tubes,  etc.  The  treatment  therefore 
should  not  be  intrusted  to  the  inexperienced. 

Many  years  ago  I  called  attention  (Amer.  Medico-Surg.  Bull.,  May 
30,  1896)  to  the  occurrence  of  gonorrheal  proctitis  as  a  complication 
of  vulvovaginitis.  The  rarity  with  which  this  complication  is  ob- 
served, notwithstanding  the  constant  exposure  of  the  anus  to  the 
gonorrheal  vaginal  discharge,  would  seem  to  prove  the  comparative 
immunity  of  the  skin  and  mucous  membrane  of  the  anus  and  rectum 
to  gonorrheal  infection.  Moreover,  proctitis  usually  does  not  develop 
until  late  in  the  course  of  the  vaginitis,  i.  e.,  until  the  skin  of  the  anus 
and  the  adjacent  structures  have  become  abraded  and  denuded  by  the 
continued  irritation  of  the  vaginal  discharge,  or  by  scratching  for  the 
relief  of  the  not  infrequently  accompanying  intense  itching. 

The  diagnosis  of  gonorrheal  proctitis  is  rendered  positive  by  the 
presence  of  the  gonococcus  in  the  mucopurulent  stools. 

Like  the  former  complication,  arthritis,  the  so-called  gonorrheal 
rheumatism,  also  develops  late  in  the  course  of  vulvovaginitis.  In  the 
majority  of  cases  the  inflammation  is  limited  to  one  joint,  usually  that 
of  the  knee,  and  occasionally  ends  in  suppuration  and  ankylosis. 

Inguinal  adenitis  is  quite  a  frequent  complication.  The  glandular 
enlargement  may  increase  up  to  a  well-marked  bubo.  It  sometimes 
suppurates  as  a  result  of  an  additional  infection  by  pus  microbes. 


DISEASES   OF    THE   KIDNEYS   AND   BLADDER  593 

The  differential  diagnosis  between  the  different  varieties  of  vulvo- 
vaginitis can  readily  be  made  by  bearing  in  mind  the  previously 
mentioned  classification.  No  examination  should  be  considered  com- 
plete without  a  very  careful  microscopical  scrutiny  of  the  vaginal  dis- 
charge. In  doubtful  cases  a  culture  will  settle  the  diagnosis.  Fur- 
thermore, it  is  well  to  remember  that  several  etiologic  factors  may 
be  operative  in  the  production  of  the  vaginitis  in  one  and  the  same 
patient.  Hence,  the  finding  of  pinworms,  for  example,  in  the  vagina 
should  not  lead  us  to  conclude  the  absence  of  gonococci. 

The  active  treatment  of  vulvovaginitis  varies  greatly  with  the 
cause.  Nongonorrheal  cases  usually  yield  promptly  to  removal  of  the 
etiologic  factors  {e.  g.,  foreign  bodies)  and  to  cleansing  of  the  genitalia 
with  salt,  boric  acid,  or  2  or  3  per  cent  permanganate  of  potash  or 
sulphoearbolate  of  zinc  solutions  and  daily  sea  salt  sitz-baths.  In  some 
cases  insufflations  of  tannic  acid,-  in  powder  form,  act  very  beneficially. 
Gonorrheal  vulvovaginitis  should  be  treated  by  instillation  into  the 
vagina  (through  a  soft-rubber  catheter)  once  a  day  or  every  other 
day  of  1/2  ounce  of  a  2  per  cent  to  5  per  cent  solution  of  nitrate  of 
silver,  followed  by  neutralization  with  salt  water;  or  a  10  per  cent 
solution  of  silvol,  argyrol,  or  solargentum.  After  subsidence  of  the 
active  symptoms  douches  with  mild  antiseptics  will  suffice.  The  sug- 
gestion recently  made  by  a  learned  clinician  to  incise  and  dilate  the 
hymen  (in  order  to  allow  free  application  of  antiseptics  to  the  vaginal 
wall)  is  here  mentioned  only  to  be  strongly  condemned. 

Gonorrheal  urethritis  in  male  children  is  treated  the  same  as  in 
the  adult. 

It  is  well  to  remember  that  recurrence  of  the  affection  after  a  period 
of  latency  is  frequent  even  under  the  most  careful  method  of  treat- 
ment. No  case  of  gonorrheal  vulvovaginitis,  therefore,  should  be 
considered  cured  unless  three  or  more  thorough  microscopic  examina- 
tions of  the  vaginal  discharge  prove  the  absence  of  gonococci  and 
pus. 

Masturbation 

(Onanism,  Thigh  Friction) 

Production  of  venereal  orgasm  by  hand,  or  other  unnatural  means, 
is  a  very  common  vice  among  school  children,  who  usually  acquire 
the  vicious  habit  from  older  playmates,  or  erotic  governesses,  etc. 
Masturbation  is  quite  common  among  mental  defectives. 

Occasionally  masturbation  is  observed  in  younger  children  and 
even  in  infants.  The  latter  may  be  seen  to  rub  their  thighs  against 
each  other  or  against  the  bosom  of  the  nurse,  or  to  exert  peculiar 


594  DISEASES   OF    CHILDREN 

rocking  motions  and  fall  back  in  a  more  or  less  marked  state  of  ex- 
haustion. 

The  effects  of  masturbation  varj^  Avith  the  frequency  and  duration 
of  the  habit  and  the  physical  condition  of  the  child.  In  the  majority 
of  cases  masturbation  produces  physical  and  mental  debility,  espe- 
cially depression  of  spirit,  headache,  palpitation  of  the  heart  and 
emaciation.  In  boys  we  may  suspect  masturbation  by  excessive 
elongation  of  the  penis,  in  girls  by  the  presence  of  vulvitis,  and  often 
stretching  of  the  hymen.  Boys  are  apt  to  suffer  from  nocturnal 
seminal  emission  and  later  also  from  impotence. 

In  remedying  this  evil,  it  is  essential  to  remove  all  local  sources 
of  irritation,  such  as  phimosis,  hypertrophy  of  the  clitoris,  pinworms, 
etc.  Infants  should  be  restrained  from  practicing  the  bad  habit  by 
mechanical  devices  (separation  of  the  thighs,  tying  of  the  hands). 
Older  children  should  be  placed  under  proper  surveillance  and  in 
suitable  spiritual  surroundings  (change  of  school  or  nurses!).  The 
general  health  should  be  improved  by  outdoor  exercise,  cold  shower 
baths,  and  by  nutritious  but  bland  diet  (no  liquors).  Bromides  are 
indicated  to  subdue  sexual  excitement.  Dime  novels  should  be  elimi- 
nated from  the  child's  reading  room. 

Menstruatio  Precox 

Genuine  precocious  menstruation  in  early  childhood  is  of  very  rare 
occurrence.  If  it  does  occur,  it  is  usually  associated  with  general 
bodily  and  mental  overdevelopment,  most  probably  due  to  pituitary 
overactivity  (see  p.  571).  The  diagnosis  of  menstruatio  precox  should 
not  be  made  until  vaginal  bleeding  from  local  injury,  from  papil- 
lomatous growths,  prolapse  of  the  urethral  mucous  membrane,  and 
hemophilia  have  been  excluded. 

Precocious  menstruation,  being  free  from  serious  consequences  to 
the  general  health,  calls  for  no  therapeutic  measures,  except  perfect 
rest  during  menstruation. 

Gangrene  of  the  Genitalia 

(Diphtheria  Vulv^,  Noma  Vulv^) 

Gangrene  of  the  genitalia  (vulva,  penis,  scrotum,  etc.)  usually  de- 
velops secondarily  to  grave  local  inflammatory  processes  in  the  vi- 
cinity. More  rarely  it  is  primary  in  nature  (after  too  liberal  use  of 
strong  antiseptic  dressings  in  open  wounds,  e.  g.,  carbolic  acid  gan- 
grene in  circumcision;  the  result  of  direct  violence,  e.  g.,  stuprum),  or 


DISEASES   OF   THE   KIDNEYS   AND  BLADDER  595 

occurs  in  connection  with  diphtheria,  dysentery,  typhoid,  and  similar 
affections. 

"Whatever  the  cause,  the  prognosis  is  always  very  serious,  fatal  ter- 
mination usually  taking  place  within  about  ten  days  from  the  onset, 
unless  we  succeed  in  checking  the  spread  of  the  gangrene  by  early 
cauterization  or  excision  of  the  affected  part.  Diphtheria  antitoxin 
is  deserving  of  trial  even  if  a  smear  or  culture  of  the  gangrenous  de- 
posit proves  negative. 


CHAPTER  XII 

DISEASES  OF  THE  NERVE  SYSTEM* 

A.  Organic  Diseases 
Hydrocephalus,  Congenital  and  Acquired 

(Acute  and  Chronic  Dropsy  of  the  Brain) 

Hydrocephalus  is  an  accumulation  of  serous,  slightly  albuminous 
fluid  within  the  cranium.  It  may  be  of  prenatal  origin  or  develop 
during  or  immediately  after  birth  as  a  result  of  traumatism  to  the 


Fig.  169. — Congenital  hydrocephalus.     (Dr.  M.  Knowlton.) 

head;  or  it  may  make  its  appearance  at  any  other  time  during  infancy 
and  childhood,  either  as  a  primary  affection  or  secondarily  to  a  num- 
ber of  acute  and  chronic  diseases.  The  fluid  may  collect  in  the  sub- 
dural space  {external  hydrocephalus)  or  in  the  ventricles  {internal 
hydrocephalus).     The   hydrocephalus   may   run   an   acute   or   chronic 


*For  "Congenital   Malformations,"   see  p.    174. 

596 


DISEASES   OF    THE    NERVE    SYSTEM 


597 


Fig.  170. — Congenital  hydrocephalus  with  spina  bifida.  Every  few  weeks  the 
hernial  sac  would  fill  up  with  cerebrospinal  fluid  and  rupture.  A  few  days  before  its 
occurrence,  there  were  distinct  symptoms  of  brain  pressure,  including  convulsions. 


Fig.  171. — Same  case  as  Fig.  170  showing  distended  spina  bifida  before  escape  of 

the  spinal  tluid. 

course.  For  detailed  description  of  chronic,  more  particularly,  con- 
genital hydrocephalus,  the  reader  is  referred  to  the  chapter  on  ' '  Hydro- 
cephalic Amentia,"  p.  710. 


598 


DISEASES   OF    CHILDREN 


In  order  to  obtain  a  clearer  understanding  of  acute  hydrocephalus, 
it  is  best  to  study  its  symptom  complex  in  connection  with  the  affec- 
tions which  form  its  underlying  pathologic  basis,  as  follows: 

1.  Meningitis  Serosa  (Acute  Internal  Hydrocephalus — Quincke). — • 
This  condition  may  complicate  acute  febrile  diseases,  such  as  pertussis, 
influenza,  pneumonia  or  typhoid,  or  set  in  primarily  in  the  same  man- 
ner as  serous  effusions  in  other  cavities  of  the  body,  e.  g.,  pleuritis, 
pericarditis,  and  the  like ;  undoubtedly  also  as  a  result  of  bacterial 


Fig.  172. — Hydroceplialus  following  meningitis. 

invasion  or  traumatism.  The  quantity  of  fluid  varies,  and  upon  its 
amount  and  the  pressure  it  exerts  upon  the  surrounding  structures 
depends  the  clinical  course.  If  the  pressure  is  great,  we  have  sopor, 
spasms,  strabismus  and  nystagmus,  and  the  head  may  assume  an 
enormous  size.  In  infants,  the  fontanelles  are  bulging,  the  cranial 
sutures  are  separated,  and  the  frontal  bone  protrudes  markedly  for- 
ward.    In  the  early  stages  of  serous  meningitis  there  is  moderate 


DISEASES   OF   THE    NERVE   SYSTEM 


599 


temperature.  If  recovery  does  not  take  place  within  a  reasonable 
time  the  patient  usually  succumbs  to  gradual  emaciation  and  increas- 
ing cachexia. 

2.  Tuherculosis  of  the  Meninges  or  Brain.  (Acute  Internal  Hydro- 
cephahis). — The  hydrocephalus  usually  develops  slowly.  The  infant  may 
be  affected  with  recurrent  attacks  of  diarrhea,  occasional  vomiting,  low 
fever,  apathy,  weakness  of  the  extremities,  and  spells  of  sudden, 
piercing  outcries,  especially  during  the  night.  Older  children  often 
complain  of  severe  headache,  are  languid  and  refuse  to  participate  in 
the  plays  of  their  comrades.  Gradually  the  symptoms  grow  worse. 
Vomiting,  rigidity  of  the  neck,  and  paralysis  of  the  cranial  nerves 
make  their  appearance,  and,  in  a  short  time  thereafter,  the  typical 
symptoms  of  cerebrospinal  meningitis  set  in,  which  sooner  or  later 
lead  to  fatal  termination.  Ordinarily  the  hydrocephalus  is  not  as 
marked  as  in  meningitis  serosa, 

3.  Wasting  Diseases,  Acute  and  Chronic. — The  hydrocephalus  is 
usually  slight,  and  hence  does  little  or  no  damage  to  the  brain.     This 


Fig.  173. — Acquired  acute  hydrocephalus,  following  acute  gastroenteritis  and  com- 
plicating rachitis.    Note  peculiar  arching  of  forehead. 


is  true  especially  of  hydrocephalus  accompanying  rachitis,  and  acute 
and  chronic  gastroenteritis.  With  subsidence  of  the  underlying  cause 
the  cranial  distention  generally  disappears;  the  disfigurement  of  the 


600  DISEASES   OF   CHILDREN 

skull,  however,  may  remain  permanent.  This  form  of  hydrocephalus 
is  sometimes  spoken  of  as  spurious. 

The  symptomatology  of  chronic  hydrocephalus,  which  occasionally 
follows  serous  meningitis  is  essentially  identical  with  that  of  congeni- 
tal hydrocephalus,  except  that  the  tendency  to  idiocy  is  not  as  great ; 
indeed  some  of  the  children  grow  up  with  practically  normal  men- 
tality. Herein,  of  course,  are  not  included  the  cases  of  hydrocephalus 
associated  with  cerebral  tumors. 

The  occasional  concurrence  of  dyspituitarism  and  hydrocephalus  has 
been  emphasized  by  Harvey  Gushing,^  L.  J.  Pollock,^  Frohlich,^  Neu- 
rath,^  Strauch,^  by  the  author,*'  and  others  to  whose  instructive  papers 
on  the  subject  the  reader  is  referred  for  further  knowledge. 

Treatment. — The  treatment  varies  with  the  etiologic  basis  of  the 
affection.  Lumbar  puncture  is  always  useful  whenever  pressure 
symptoms  become  evident,  and  in  young  infants  we  may  also  resort 
to  puncture  of  the  lateral  ventricles.  As  hydrocephalus  is  sometimes 
a  manifestation  of  congenital  syphilis,  specific  treatment  is  worth 
trying,  even  though  the  Wassermann  reaction  may  prove  negative. 
For  further  information  the  reader  is  referred  to  the  chapter  on 
"Idiocy".) 

Anemia  of  the  Brain 

(  H  YDBOCEPHALOID  ) 

This  condition  is  usually  the  result  of  excessive  loss  of  body  fluids 
(repeated  hemorrhages),  general  grave  anemia,  exhaustion  from  acute 
(rarely  chronic),  gastrointestinal  diseases,  interference  with  the  blood 
supply  of  the  brain  (pressure  on  the  part  of  tumors),  etc.  If  the 
anemia  is  moderate,  it  is  manifested  principally  by  syncope. 

Anemia  of  the  brain  occuring  in  violent  gastroenteric  affections  (with 
profuse  vomiting  and  diarrhea)  is  generally  spoken  of  as  "hydroceph- 
aloid, ' '  so  designated  by  Marshall  Hall,  who  first  described  the  symptom 
complex.  Hydrocephaloid  is  characterized  by  a  stage  of  excitation: 
flushed  face,  fever,  restlessness,  jactitations;  and  one  of  prostration: 
pallor,  sunken  face,  irregular  pulse  and  respiration,  cold  extremities, 
subnormal  temperature,  sunken  fontanelles,  stupor  with  half-closed 
eyes,  hazy  corneae,  coma,  convulsions,  and,  as  a  rule,  death. 

»"The  Pituitary  Body  and  its  Disorders,"   1911. 

^Hypopituitarism  in  Chronic  Hydrocephalus,  Jour.  A.   M.   A  ,  Jan.   30,   1915. 

'Wien.  khn.  Rundschau,  No.  45,  1901. 

<Wien.  klin.  Wchnschr.,  No.  2,  1911. 

"Jour.  A.  M.  A.,  June  14,  1919. 

«"The  Backward  Baby,"  p.  56. 


DISEASES   OF   THE    NERVE   SYSTEM       -if^^/^  *^    '  601 

''  ^  L  I-  E'  G  7  '-.  :  ^  7-  -■  ■ 
Occasionally  hydroeeiihaloid  yields  to  ener^ejtip. treatment,  which  con- 
sists of  external  heat,  transfusion,  stimulation  by  entero-  and  hypo- 
dermoclysis,  intravenous  saline,  sterile  camphorated  oil  and  strychnine 
hypodermically ;  champagne  and  small  quantities  of  food  by  mouth. 
Fresh  air. 

The  brain  of  infants  dying  from  cerebral  anemia  is  pale,  watery  and 
softer  than  normal. 

Hyperemia  of  the  Brain 

The  hyperemia  may  be  active  or  arterial ;  passive  or  venous. 

Active  hyperemia  may  occur  as  a  result  of  sunstroke,  traumatism, 
mental  or  physical  overexertion,  overstimulation  by  exhilarating  bev- 
erages or  drugs,  hysteria,  onset  of  acute  infectious  diseases,  etc. 

It  is  manifested  by  deep  redness  of  the  face,  congestion  of  the  con- 
junctivae, contraction  of  the  pupils,  hot  skin,  high  temperature,  ac- 
celerated pulse,  strong  pulsation  of  the  carotids  and  temporals,  ring- 
ing in  the  ears,  intense  headache,  excessive  thirst,  and  in  severe  cases 
convulsions,  dilirium,  distention  of  the  fontanelles,  and  other  symp- 
toms of  meningeal  irritation. 

Passive  hyperemia  of  the  brain  is  caused  by  passive  congestion  of 
the  cerebral  veins  owing  to  cardiac  debility,  grave  pulmonary  affec- 
tions (edema,  pertussis,  etc.),  compression  of  the  veins  in  the  neck, 
etc. 

The  symptoms  of  passive  hyperemia  are  those  of  exhaustion,  apathy, 
somnolence,  cyanosis  of  the  face  and  dyspnea. 

Treatment. — The  treatment  depends  upon  the  original  condition. 
It  is  more  or  less  symptomatic — antiphlogosis  in  the  active,  stimula- 
tion in  the  passive  variety  of  hyperemia. 

Upon  the  underlying  cause  also  depends  the  final  outcome.  Pro- 
tracted hyperemia  sooner  or  later  leads  to  meningitis,  rupture  of  cere- 
bral blood  vessels,  and  dropsical  effusion  in  the  cranial  cavities. 

General  Remarks  on  Cerebral  or  Central  Paralysis  and 
Brain  Localization 

"Cerebral  paralysis,"  so-called,  is  not  an  independent  brain  dis- 
ease, but  merely  a  symptom  occurring  in  connection  with  a  number 
of  congenital  and  acquired  brain  affections.  Depending  upon  the  ex- 
tent of  the  lesion  in  the  brain  the  paralysis  may  appear  either  in  the 
form  of  hemiplegia,  double  hemiplegia,  or  monoplegia. 

Hemiplegia  is  the  result  of  a  lesion  (disease  or  trauma)  in  one  cere- 
bral hemisphere.    The  paralysis  is  situated  on  the  side  opposite  that 


602 


1  -^  DISEASES   OF    CHILDREN 

1  c  n  -  -^RAIN  LOCALIZATION 


0  -iPMl'.- 


,_,in4-;2-^;M4^ 


Seiat  of  Lesion 


Usual  Manifestations  and  Their  Seat 


Central  convolutions: 

1.  Upper  third. 

2.  Middle   third. 

3.  Lower  third. 

(a)   Upper  part, 

(&)  Lower  part. 

Frontal  convolutions. 
Parietal  convolutions. 

Occipital     convolutions;     (especially     cu- 

neus). 
Temporal   convolution?. 

Centrum  ovale. 

Central  ganglia    (caudate  aiid  lenticular 

nuclei) . 
Optic  thalamus. 
Internal  capsule. 

Corpora  quadrigemina  (anterior  pair). 

Crura  cerebri. 

Pons  and  medulla  (one-half). 


Cerebellum. 


Paralysis  of  leg,  opposite  side;  convul- 
sions. 

Paralysis  of  arm,  opposite  side;  convul- 
sions. 

Paralysis  of  the  muscles  of  one-half  of 

the  face. 
Paralysis  of  the  muscles  of  the  lips  and 

tongue. 
Disturbance  of  speech. 
Disturbance  of  cutaneous  and  muscular 

sensibility. 
Hemiopia;   loss  of  visual  memory. 

Disturbance    of    hearing,    opposite    side, 

and  sense  of  smell. 
Monoplegia,  hemiplegia,  hemiopia,  word 

deafness  and  aphasia:  convulsions. 
Hemiplegia  and  hemianesthesia. 

Disturbance  of  vision  up  to  blindness. 

Hemiplegia  and  hemianesthesia,  and 
sometimes  loss  of  special  senses. 

Oculomotor  paralysis,  reeling  gait,  pos- 
sibly total  blindness  and  deafness. 

Hemiplegia  with  cross  paralysis  of 
oculomotor  nerve. 

Hemiplegia  with  cross  paralysis  of  fa- 
cial nerve;  hemianesthesia;  also  in- 
volvement of  other  cranial  nerves,  e.  g., 
hypoglossal,  abducens,  varying  with 
tlie  height  of  the  lesion. 

Ataxia,  vertigo,  and  vomiting. 


of  the  lesion.  Motile  power  may  be  completely  abolished  or  only 
partially  so  (paresis).  Sensation  may  remain  intact,  but  is  lost  if 
the  brain  lesion  is  in  the  internal  capsule  and  extends  to  the  sensory 
fibers.  The  paralysis  is  associated  with  spastic  rigidity  of  the  affected 
muscles,  exaggeration  of  the  deep  reflexes,  implication  of  some  of 
the  cranial  nerves,  such  as  the  facial  (palsy  of  the  loAver  part  of  the 
face),  hypoglossal  (deviation  of  the  tip  of  the  tongue  to  healthy  side), 
and  ocular  nerves  (nystagmus,  hemianopsia,  and  optic  atrophy),  and 
occasionally,  in  a  left-sided  lesion,  also  with  motor  aphasia.  As  the 
paralysis  becomes  chronic  the  paretic  musculature  shows  a  tendency 


DISEASES   OF    THE    NERVE   SYSTEM  603 

to  arrest  of  development,  tremor  and  athetosis;  and  epilepsy  and 
mental  impairment  up  to  total  idiocy  make  their  gradual  appearance. 

Diplegia  (double  hemiplegia)  may  be  the  result  of  two  separate  at- 
tacks of  hemiplegia.  INFore  frequently  it  develops  with  one  attack 
as  a  sequel  of  extensive  brain  lesions  in  both  cerebral  hemispheres  or 
in  the  pons  and  medulla  (affecting  both  lateral  halves).  If  only  one 
side  of  the  pons  is  involved,  we  have  cross  paralysis  of  the  extrem- 
ities on  one  side  and  of  the  facial  nerve  on  the  other  side. 

In  double  hemiplegia,  in  addition  to  the  symptoms  enumerated  un- 
der hemiplegia,  functions  may  suffer  which  escape  ordinary  hemi- 
plegia, e.  g.,  that  of  swallowing  and,  perhaps,  that  of  micturition.  Oc- 
casionally it  is  accompanied  also  by  paralj'sis  of  the  tongue,  giving  rise 
to  symptoms  which  closely  resemble  those  associated  with  bulbar 
paralysis.  However,  there  is  no  wasting  of  the  tongue,  nor  change 
in  the  electric  reaction;  hence,  is  spoken  of  as  ''pseudobulbar  paraly- 
sis." 

Monoplegia  as  a  primary  manifestation  of  a  cerebral  paralysis  is 
rare.  More  frequently  it  is  met  in  the  regressive  stage  of  the  afore- 
mentioned two  types  of  paralysis  or  in  connection  with  lesions  of  the 
spinal  cord  or  peripheral  nerves.  Cerebral  monoplegia  usually  arises 
from  a  limited  lesion  in  or  near  the  cortex  {e.  g.,  in  simple  encephalitis), 
less  frequently  from  smaller  capsular  lesions  involving  individual 
nerve  bundles  for  the  face,  arm,  leg,  etc. 

Intracranial  Hemorrhage 
(Meningeal  Hemorrhage,  Hemorrhage  in  the  Brain) 

We  had  occasion  (p.  208)  to  direct  attention  to  hemorrhages  result- 
ing from  obstetrical  injuries.  This  space  will  be  devoted  to  the  dis- 
cussion of  intracranial  hemorrhages  occuring  during  infancy  and 
childhood.  The  usual  sites  for  intracranial  hemorrhages  are  as  fol- 
lows :  neighborhood  of  the  large  central  ganglia,  pons,  meninges, 
convolutions,  cerebellum,  crura  cerebri  or  medulla. 

They  may  occur  as  a  result  of  trauma,  such  as  a  blow  or  fall  upon 
the  head;  in  association  with  meningitis,  infectious  diseases,  purpura, 
pertussis  (as  a  result  of  severe  venous  congestion)  ;  sinus  thrombosis, 
syphilis  (syphilitic  arteritis),  richly  vascular  tumors;  nephritis  and 
hypertrophy  of  the  heart  (owing  to  increased  blood-pressure),  etc. 

In  the  majority  of  instances  the  symptomatology  is  at  first  indefinite 
and  inseparable  from  that  of  the  fundamental  disease.  Where  the 
hemorrhage  is  extensive,  the  symptom  complex  resembles  in  its  en- 
tirety that   observed  in  intracranial  hemorrhage  in  adults.     Thus: 


604  DISEASES   OF    CHILDREN 

unconsciousness,  convulsions,  slow,  irregular  breathing,  slow  and  full 
pulse,  coma  and  death,  or  partial  recovery  with  persistent  focal  signs, 
especially  paralysis  (hemiplegia,  diplegia  or  monoplegia). 

Treatment. — The  treatment  consists  of  an  ice  cap  to  the  head, 
counterirritation  (wet  cups  to  nape  of  neck),  perfect  rest,  light  nutri- 
tious diet,  and  later,  ergot  and  the  iodides.  In  traumatic  cerebral 
hemorrhage  early  operative  interference  is  indicated.  Pressure  symp- 
toms may  be  relieved  by  lumbar  puncture. 

Embolism  of  the  Brain  Arteries 

Cerebral  embolism  like  hemorrhage  is  rarely  observed  in  children. 
It  is  occasionally  met  in  connection  with  severe  valvular  heart  dis- 
ease, and  acute  infectious  and  pyemic  processes,  and  most  frequently 
affects  the  arteria  fossae  Sylvii. 

The  symptomatology  of  embolism  is  practically  the  same  as  in  cere- 
bral hemorrhage  (q.  v.),  except  that  in  the  former  the  signs  of  cerebral 
compression  and  shock  are  not  as  persistent  and  as  severe.  Furthermore, 
the  existence  of  valvular  heart  trouble  decides  in  favor  of  embolism.  The 
onset  is  usually  sudden  (occasionally  preceded  by  headache,  A'omiting, 
etc.),  with  convulsions,  coma,  etc.,  followed  either  by  early  death,  or 
partial  recovery,  with  remaining  focal  symptoms,  especially  hemi- 
plegia and  aphasia.    In  septic  embolism  there  is  irregular  fever. 

Treatment. — The  treatment  is  the  same  as  in  cerebral  hemorrhage. 
Antisyphilitic  treatment  may  be  tried  in  eases  of  doubtful  origin. 

Sinus  Thrombosis 

Thrombosis  in  the  large  sinuses  of  the  dura  mater  is  most  frequently 
observed  in  debilitated  infants.  Two  forms  are  distinguished:  pas- 
sive or  marantic,  being  the  result  of  retardation  of  the  venous  blood 
current  in  severe  cardiac,  gastrointestinal,  or  other  exhausting  dis- 
eases; active  or  infective,  occurring  in  connection  with  inflammatory 
processes  in  the  vicinity,  e.  g.,  ear,  nose,  eyes,  etc. 

Passive  simis  thrombosis  is  usually'  limited  to  the  longitudinal  sinus 
and  is  manifested  by  symptoms  of  exhaustion  and  collapse  and  those 
of  hydrocephaloid  plus  local  edema  and  distention  of  the  veins  of 
the  head  and  face. 

Active  sinus  thrombosis  usually  involves  the  transverse  and  petro- 
sal sinuses  and  is  characterized  in  addition  to  the  aforementioned 
phenomena  by  more  or  less  marked  septic  symptoms  (vomiting,  chills 
and  fever,  etc.),  hemorrhagic  infarcts  and  embolism,  e,  g.,  in  the  lungs, 
spleen  and  other  organs  of  the  body. 


DISEASES  OF   THE   NERVE  SYSTEM  605 

The  differential  diagnosis  between  the  two  varieties  of  sinus  throm- 
bosis is  quite  difificult,  but  somewhat  facilitated  by  lumbar  puncture, 
which  in  the  infective  form  reveals  in  the  hemorrhagic  cerebrospinal 
fluid  numerous  bacteria  (strepto-  or  staphylo-,  or  pneumococci).  When 
the  longitudinal  sinus  is  involved,  there  are  epistaxis,  cyanosis  of  the 
face,  edema  of  the  soft  tissues  of  the  frontal,  parietal  and  temporal  re- 
gions and  frontal  sweating.  When  the  transverse  and  petrosal  of  one 
side  are  affected,  corresponding  collapse  of  the  jugular  vein  and  edema 
of  the  mastoid  region  result.  When  the  cavernous  sinus  is  implicated, 
exophthalmos,  chemosis  of  the  conjunctivae  and  lids  are  the  distinctive 
signs. 

Treatment. — Where  a  diagnosis  can  be  established  early,  opening 
of  the  sinus  may  prove  a  life-saving  operation  in  septic  sinus  throm- 
bosis. Otherwise  little  can  be  accomplished  in  the  way  of  therapy. 
In  marantic  sinus  thrombosis,  active  stimulation  may  act  well  in  some 
cases.  The  prognosis,  thus  being  so  extremely  grave,  our  attention 
should  be  directed  principally  toward  prophylaxis,  especially  as  re- 
gards extension  of  the  suppurative  process  from  neighboring  struc- 
tures. 

MENINGITIS  ACUTA 

(  MENINGITIS  CEREBROSPINALIS) 

Meningococcic,  Pnemnococcic,  Tuberculous,  Streptococcic,  Etc.,  Men- 
ingitis^ 

Meningitis  may  be  primary  or  secondary  in  nature.  Primary  men- 
ingitis may  be  the  result  of  traumatism  (may  involve  both  the  dura 
mater — pachymeningitis  hemorrhagica — and  pia  mater,  but  usually  the 
former)  or  may  be  due  to  direct  infection  of  the  meninges  by  the  diplo- 


'Our  venturesome  attempt  to  disrupt  the  time-worn  mode  of  grouping  of  the  different 
varieties  of  meningitis  is  based  upon  the  following  considerations.  1.  The  symptom  complex 
of  fully  established  meningeal  inflammation  is  practically  identical  in  all  forms  of  the  disease, 
and  differs  only  in  the  degree  of  mildness  or  severity  of  the  attack,  which  depends  upon  the 
extent  of  the  lesion,  the  susceptibility  and  the  power  of  resistance  of  the  patient  to  the  microbic 
toxin  and  its  baneful  effects.  2.  The  same  lack  of  distinction  is  observed  in  the  pathologic 
anatomy  of  the  divers  forms  of  meningitis,  except  that  in  tuberculous  meningitis  we  find  in 
addition  to  the  usual  inflammatorj'  process,  local  or  general  dissemination  of  tubercles,  which, 
however,  are  not  manifested  by  special  clinical  sumptoms.  3.  Even  the  formerly  accepted  view 
as  to  the  characteristic  distribution  of  the  inflammation  in  certain  varieties  of  the  affection, 
e.  g.,  the  so-called  "vertical"  or  "basilar"  meningitis,  etc.,  is  no  longer  scientifically  tenable  in 
a  strict  sense  of  the  word,  since  meningitis  of  the  convexity  of  today  may,  by  extension,  be- 
come that  of  the  base  the  day  following  and  vice  versa.  With  these  considerations  in  view,  and 
appreciating  also  the  fact  that  a  positive  differential  diagnosis  of  the  variety  of  meningitis 
can  be  made  only  by  the  findings  of  the  etiologic  factors  in  the  cerebrospinal  fluid  obtained  by 
lumbar  puncture,  we  feel  fully  justified  to  discard  the  subdivision  of  meningitis  into  "serous," 
"purulent,"  "epidemic,"  "posterior-basic,"  etc.,  and  to  classify  the  disease  from  an  etiologic 
point  of  view.  Just  as  we  speak  of  "tuberculous  meningitis,"  we  speak  also  of  meningococcic, 
pneumococcic,#  streptococcic,  influenzal  meningitis,  etc. — a  classification  which  is  not  only 
scientifically  correct,  but  at  once  offers  a  clue  as  to  the  etiology,  mode  of  treatment,  and 
prognosis. 


606  DISEASES   OF   CHILDREN 

COCCUS  intracellularis  meningitidis*  (Weichselbaum,  Leichtenstern  and 
Jager)  and  other  pathogenic  bacteria,  e.  g.,  streptococci  or  staphylococci, 
and  affect  the  pia  mater  of  the  brain  as  well  as  the  cord — cerebrospinal 
meningitis.  Secondary  meningitis  is  due  to  extension  of  the  infection 
from  neighboring  or  more  remote  parts.  This  form  includes  the  tuber- 
culous, or  pneumococcus  meningitis,  as  well  as  the  meningitides  which 
are  met  with  in  divers  acute  infectious  diseases,  such  as  influenza,  ty- 
phoid fever,  erysipelas,  otitis,  diphtheria  and  the  like.  The  infection 
spreads  either  by  continuity  (throat,  nose  or  ear),  by  the  lymphatics, 
or  by  the  blood  vessels. f 

Meningitis  is  a  disease  peculiar  to  early  childhood,  the  majority  of 
eases  occurring  in  the  first  three  years  of  life.  It  prevails  principally, 
often  in  epidemic  form  (epidemic  cerebrospinal  meningococcus  or  malig- 
nant meningitis)  during  the  late  winter  and  spring  months,  at  a  time 
when,  with  rapid  changes  in  the  weather  and  crowding  of  the  children  in 
stuffy  rooms,  "colds"  and  their  sequelas  are  fiercely  rampant.  It  is  ob- 
served also  sporadically  during  all  seasons  of  the  year.  Delicate  chil- 
dren are  more  prone  to  be  attacked  than  robust  ones,  this  being  the 
case  especially  with  tuberculous  meningitis,  which  is  frequently  the  cul- 
mination of  latent  tuberculosis  of  Other  organs  of  the  body. 

The  mode  of  onset  of  the  disease  varies  greatly.  It  is  usually  abrupt 
in  primary  meningitis,  rarely  preceded  by  a  few  indefinite  signs  of  ill 
health,  such  as  anorexia,  restlessness  and  headache.  In  secondary  menin- 
gitis the  attack,  as  a  rule,  develops  more  insidiously  and  is  often  obscured 
by  the  symptomatology  of  the  preceding  affection.  Meningitis  super- 
vening latent  tuberculosis  with  few  exceptions  is  particularly  prone  to 
be  gradual  in  its  development.  In  these  cases  the  child  may  for  weeks 
manifest  apathy,  anorexia,  vomiting,  wasting,  occasional  rise  of  tempera- 
ture, and  other  symptoms  corresponding  to  the  seat  of  the  original  lesion 
{e.g.,  caseation  of  the  bronchial,  mesenteric,  or  intestinal  glands;  bone 
or  joint  disease,  etc.). 

Acute  meningitis,  be  it  primary  or  secondary,  gives  rise  to  dizziness, 
headache,  nausea,  projectile  and  usually  persistent  vomiting,  rise  of  tem- 
perature, jactitations  up  to  convulsions,  alternating  with  drowsiness, 
stiffness  and  pain  in  the  neck.  This  group  of  symptoms,  while  per  se 
not  at  all  characteristic,  is  nevertheless  strongly  suspicious  of  the  dis- 
ease.    Finding  a  patient  in  this  condition  we  should  at  once  carefully 


*Type   A,    B,    C,   or    D.      See   p.    78. 

tBy  special  care  in  preparation  of  mediums  and  other  details,  Marshall  A.  Barber.  Captain. 
S.  C.,  N.  A.,  and  J.  I'\  Fleming,  First  I^ieutenant,  M.  R.  C,  have  obtained  positive  blood 
cultures  in  twelve  cases.  Recent  experience  would  indicate  that  with  early  diagnosis  and 
proper  laboratory  technic  the  meningococcus  may  be  grown  from  the  blood  in  from  50  to  80 
per  cent  of  all  cases  of  epidemic  meningococcus  infection.  W.  W.  Ilerrick:  J.  A.  M.  A.,  Aug. 
24,    1918. 


DISEASES   OF    THE    NERVE   SYSTEM 


607 


examine  liim  for  the  followin.?  more  or  less  pathognomonic  physical 
signs  and  symptoms  of  meningitis: 

Opisthotonos  or  Rigidity  of  the  Neck  and  Brudzinshi's  Sign. — This 
symptom  is  elicited  by  placing  the  hand  under  the  patients'  occiput 
and  flexing  the  head  upon  the  chest.  In  meningitis  the  neck  will  be 
found  stiff  and  painful.  Forcible  flexion  of  the  head  upon  the  chest 
usually  produces  synchronous  flexion  of  the  legs  upon  the  abdomen 
(Brudzinski's  sign).  The  child  instinctively  assumes  a  lateral  position, 
as  the  dorsal  position  proves  very  painful  by  pressure  of  the  head 
against  the  pillow.  Rigidity  of  the  neck  is  present  at  one  time  or  an- 
other in  all  cases  of  meningitis.  It  is  especially  pronounced  in  cases 
in  which  the  inflammation  begins  at  the  posterior  part  of  the  brain. 
As  the  disease  advances  the  rigidity  extends  to  the  muscles  of  the  back 
and  extremities,  gives  rise  to  a  spasmodic  rigidity  of  the  body  in  which 
the  trunk  is  arched  forward  and  the  shoulders  and  buttocks  are  thrown 
backward  while  the  legs,  as  a  rule,  are  flexed  upon  the  thighs — opisthot- 


Fig.  174. — Epidemic  cerebrospinal  meningitis.     (After  Pfaundler  and  Schlossmann.) 

onos.  Occasionally  the  forearms  are  extended  and  the  fingers  clenched 
in  the  palm. 

Kernig's  Sign. — This  symptom  consists  of  inability  of  the  examiner 
to  extend  the  patient's  legs  with  the  thighs  flexed  on  the  abdomen. 
It  is  met  in  the  majority  of  cases  of  meningitis,  but  it  is  not  entirely 
pathognomonic  of  the  disease,  since  it  is  observed  also  in  other  af- 
fections, e.  g.,  typhoid  fever,  and  occasionally  also  in  normal  infants. 
In  conjunction,  however,  with  the  other  m.eningeal  symptoms  Kernig's 
sign  is  very  helpful  in  the  diagnosis. 

Bahinski's  Reflex. — Irritation  of  the  plantar  surface  of  a  patient 
suffering  from  meningitis  produces  extension  of  the  great  toe  with 
flexion  of  the  other  toes.  It  is  a  characteristic  sign  of  disease 
of  the  pyrimidal  and  lateral  tracts  of  the  cord,  hence  is  more  apt  to  be 
observed  i;i  very  diffuse  forms  of  inflammation  (tuberculosis)  of  the 
meninges  and  underlying  structures  than  in  the  localized  forms  of  the 


608  DISEASES   OF   CHILDREN 

disease.  This  sign  is  least  reliable  in  infants  under  two  years  of  age, 
but  is  of  corroborative  value  in  older  children. 

Leichtenstern's  Sign. — This  consists  of  lightning-like  contraction  of 
the  whole  body  on  striking  any  part  of  the  bony  framework  with 
the  percussion  hammer.  It  is  a  symptom  of  meningitis,  principally  dur- 
ing the  stage  of  irritation. 

Reflexes. — In  the  early  stages  of  meningitis  the  skin  and  tendon 
reflexes  are  somewhat  exaggerated,  but  with  the  gradual  loss  of  mus- 
cular power  they  disappear  partially  or  wholly. 

Changes  in  the  Eyes. — Intolerance  to  light  and  contraction  of  the 
pupils  form  early  symptoms  of  meningitis.  Dilatation  or  inequality 
of  the  pupils  is  usually  met  with  later.  The  inequality  is  usually 
transient  and  variable,  present  at  one  time  and  absent  at  others :  now 
one  pupil,  now  the  other  may  be  the  larger.  Strabismus  and  nystag- 
mus are  observed  in  advanced  stages  of  the  affection.  Examination  of 
the  fundus  reveals,  in  the  majority  of  cases  of  tuberculous  meningitis, 
optic  neuritis  or  papillitis,  and  tubercles  in  the  choroid.  Optic 
neuritis  is  occasionally  found  also  in  other  varieties  of  meningitis, 
chiefly  when  the  base  is  involved.  After  the  first  week  the  child 
often  keeps  the  eyes  open  staring  immovably  into  distance. 

Vasomotor  and  Cutaneous  Disturbances. — Cutaneous  irritation  is 
usually  followed  by  a  vivid  and  enduring  congestion  of  the  skin — 
tallies  cerehrales  (Trousseau's  sign).  This  symptom  is  not  very  signif- 
icant, being  observed  also  in  other  infectious  diseases,  e.  g.,  typhoid  fe- 
ver. Eruptions  of  the  skin — erythema,  herpes,  urticaria  and  purpura — 
are  quite  frequent.  Purpuric  spots  are  especially  common  in  fulminant 
cases  (hence  often  spoken  of  as  spotted  brain  fever).  They  vary  in 
size  and  may  coalesce  to  form  dark  diffuse  extravasations  into  the  skin. 

McE wen's  Sign. — With  the  patient  in  an  upright  position  and  his 
head  inclined  to  one  side,  percussion  over  the  junction  of  the  lower 
portions  of  the  frontal  and  parietal  bones  gives  a  tympanitic  note. 
This  situation  corresponds  to  the  anterior  horn  of  the  lateral  ventricle, 
and  the  note  is  caused  by  the  presence  of  fluid  in  the  ventricle.  Hence 
it  is  most  frequently  observed  in  the  tuberculous  variety  of  men- 
ingitis, where  there  is  an  accumulation  of  fluid  in  the  ventricles. 
This  sign  is  not  pathognomonic  before  complete  ossiflcation  of  the 
skull. 

Mental  State. — In  the  beginning  of  the  disease  the  children  are 
usually  very  irritable.  They  twitch,  grind  the  teeth,  start  up  with 
a  cry  of  alarm  when  disturbed,  are  annoyed  by  the  least  sound 
in  the  room;  but  as  the  meningitis  progresses,  or  in  the  tubercu- 


mSEASES  OF   THE  NEUVE  SYSTEM  609 

lous  variety  often  at  its  very  inception,  the  patient  gradually  enters 
into  a  state  of  apathy,  stupor  and  coma. 

Blood. — There  is  generally  a  high  leucocytosis  (as  high  as  45,000 
to  55,000  per  cubic  millimeter,  rarely  below  20,000)  in  the  nontuber- 
culous  forms. 

The  experienced  clinician,  in  order  to  arrive  at  a  conclusion,  rarely 
needs  to  wait  for  the  synchronous  inauguration  of  all  of  the  afore- 
mentioned symptoms.  Indeed,  it  is  quite  uncommon  to  meet  with 
cases  which  present  such  an  array  of  typical  phenomena.  One  seldom 
errs  in  the  diagnosis  where  persistent  vomiting,  convulsions,  rigidity, 
photophobia  and  stupor  are  grouped  together.  However,  the  mere 
diagnosis  of  meningitis  is  not  sufficient.  It  is  also  the  cause  and  vari- 
ety we  are  interested  in. 

Cerebrospinal  Fluid. — With  the  latest  improvements  in  the  technic 
of  examination  of  the  cerebrospinal  fluid  obtained  by  lumbar  punc- 
ture, numerous  doubtful  points  of  diagnosis  can  be  cleared  up  which 
before  the  introduction  of  this  diagnostic  procedure  forever  remained 
a  mystery. 

Normal  cerebrospinal  fluid  is  a  clear  neutral  or  slightly  alkaline 
fluid,  containing  but  a  small  proportion  of  salines,  a  small  quantity 
(0.05  to  0.1  per  cent)  of  serum  globulin,  a  trace  of  cholin  and  a  sugar- 
reducing  agent  (0.5  per  cent).  It  is  not  spontaneously  coagulable.  Its 
specific  gravity  varies  between  1,007  to  1,009. 

In  normal  individuals  it  escapes  through  the  puncture  needle  at  a 
low  pressure,  usually  drop  by  drop.  The  pressure  may  accurately  be 
measured  by  the  manometer,  but  the  experienced  eye  can  well  appre- 
ciate the  amount  of  tension  by  observing  the  force  of  the  jet. 

The  pressure  is  usually  increased  in  divers  meningeal  irritations  and 
is  particularly  high  in  tuberculous  and  hydrocephalic  conditions.  As 
the  stream  may  be  altered  by  the  position  of  the  patient,  by  the  viscosity 
of  the  fluid,  by  interference  with  the  flow  in  its  path  etc.,  the  semio- 
logic  importance  of  pressure  is  rather  slight. 

The  color  of  the  cerebrospinal  fluid  may  be  altered  by  accidental  or 
pathologic  admixture  of  blood,  pus  or  pigment.  In  acute  bacterial  men- 
ingitis the  discoloration  varies  from  slight  cloudiness  to  a  well-defined 
purulent  turbidity.  In  tuberculous  miningitis  the  fluid  is  usually  clear 
or  slightly  opalescent;  on  standing  a  thin  film  forms  on  the  upper  sur- 
face. The  presence  of  blood  is  readily  recognized  and  may  be  due  to  ac- 
cidental adjnixture  from  the  puncture  wound  or  to  hemorrhagic  pachy- 
meningitis. 


610 


DISEASES    OF    CHILDREN 


The  hacteriologic  examination  of  the  cerebrospinal  fluid  is  of  inesti- 
mable clinical  value,  since  it  often  furnishes  reliable  information  not 
only  as  to  early  diagnosis,  but  to  the  prognosis  and  treatment  as  well. 
Too  much  stress  cannot  be  laid  upon  the  fact  that,  in  order  to  obtain 
conclusive  pathologic  data,  the  examination  of  the  fluid  should  be  in- 
trusted to  one  thoroughly  experienced  in  bacteriology  and  microscopy. 
Negative  results  in  the  majority  of  instances  are  due  to  skepticism  and 
faulty  technic.  Occasionally  repeated  examinations  are  required.  Nearly 
all  kinds  of  microorganisms  have  been  found.     Careful  search  for  the 


Fig.  175. — Lumbar  puncture.  Thv  patient  is  put  near  the  edge  of  a  table  in 
sitting  or  lying  posture,  with  the  vertebral  column  strongly  arched  forward.  The 
puncture  is  made  with  a  thin,  hollow  exploratory  needle  in  the  lumbar  region,  in  the 
third  or  fourth  intervertebral  space,  at  a  point  corresponding  to  a  line  drawn  between 
the  superior  crests  of  the  ilia. 


tubercle  bacillus  should  be  made  in  all  cases  of  meningitis,  regardless  of 
clinical  data.  The  finding  of  the  tubercle  bacillus  in  the  cerebrospinal 
fluid  at  a  glance  settles  the  diagnosis,  where  volumes  of  descriptions  of 
differential  features  at  best  fail.  The  same  applies  for  the  diplococcus 
intracellularis  meningitidis,  and  other  pathogenic  bacteria. 


DISEASES   OP    THE   NERVE   SYSTEM 


611 


CERKBROSPIXAL,   FI^UIDS 
(After   Dr.   A.    Sophian) 


Normal 

Mcningism 

Poliomyelitis 
Polioenceph- 
alitis 

Cerebrospinal 
Meningitis 

Streptococcus, 

Pneumococcus, 

Influenza,  etc., 

Meningitis 

Tuberculous 
Meningitis 

Color 

Clear 

Clear 

Clear 

Cloudy — pus 
sediment 

Cloudy — pus 
sediment 

Clear — white 
flakes — fibrin- 
network 

Pressure 

Low — escapes 
slowly    drop 
by    drop 

+ 

-f 

-♦•-)■ 

+  + 

-l--l--t- 

Quantity 

Little — few 
c.c 

+  (up  to  SO 
c.c.  or  more) 

f  (up  to  SO 
c.c.  or  more) 

+  +  (up  to  100 
c.c.  or  more) 

+  +  (up  to  100 
c.c.  or  more) 

+++  (up  to  100 
c.c.  or  more) 

Cytology 

Few  cells,  leu- 
kocytes and 
endothelial 

Few  cellular 
elements 

Cells  increas- 
ed   (+)    in 
number.  Lym- 
phocytes 
90%  or  more 

Cells  numerous 
-H--I-  (Polynu- 
clear  up  to 
100%) 

Cells  numerous 
-l--^-f  (Polynu- 
clear  up  to 
100%) 

Cells  numerous 
++  (Lymph- 
ocytes up  to 
90%) 

Bacteri- 
ology 

Sterile 

Sterile 

Sterile 

Meningococcus 

Infecting  or- 
ganism 

Tubercle  bacil- 
lus 

Albumin 
(nitric  acid 
test) 

Faint    trace 

Trace 

Trace 

+  +  + 

-J-  +  -H 

+ 

Fehling's 
Solution 

Reduces 

Reduces 

Reduces 

Unreliable 

Unreliable 

Unreliable 

Globulin 
Test 

Negative 

Negative 

Positive  in 
early  stages 

+  +  + 

+  +  + 

+  + 

For  the  detection  of  the  microorganism  we  may  use  stained  smears 
(the  specimen  having  been  obtained  from  the  coagulum  that  forms  in 
the  fluid  on  standing  or  after  centrifugation),  cultures,  or  inoculation 
methods.  Where  rapid  decision  is  demanded  the  last  two  procedures  are 
not  adoptable,  but  as  their  scientific  accuracy  is  incontestable  they  are 
not  rarely  indispensable  in  cases  of  obscure  origin  and  especially  in 
mixed  infections. 

Cytodiagnosis. — This  is  based  upon  the  histologic  study  and  deter- 
mination of  the  number  and  nature  of  the  formed  elements  in  the  cere 
brospinal  fluid.  Normally  this  fluid  contains  very  few  cells,  so  few 
that  in  a  smear  obtained  from  the  deposit  after  centrifugation  only 
two  or  three  leucocytes  may  be  visible  in  the  microscopic  field.  The 
presence  of  leucocytes  in  great  numbers  constitutes  anatomic  evidence  of 
a  meningeal  lesion — namely,  of  tuberculous  nature,  where  lymphocytes* 
(mononuclears)  prevail,  and  nontuberculous,  where  polymorphonuclear 
leucocytes  predominate.  This  rule  applies  only  to  cases  which  are 
neither  very  recent  nor  very  protracted,  i.  e.,  to  the  fully  developed 
acute  disease,  since  lymphocytosis  is  found  in  nontuberculous  meningitis 
tending  to  recovery,  in  acute  syphilitic  meningitis,  and  in  other  chronic 


*See  Encephalitis  Lethargica,  p.  624. 


612 


DISEASES   OF   CHILDREN 


brain  affections,  while  polynucleosis  is  occasionally  associated  with 
lymphocytosis  in  chronic  tuberculous  meningitis. 

Of  interest  chemically  are  the  facts  that  in  meningitis  the  proportion 
of  chlorides  in  the  cerebrospinal  fluid  is  often  reduced  while  that  of  al- 
bumin is  increased.  The  albumin  consists  principally  of  serin,  while 
normally  it  is  mostly  globulin.  The  fibrin  is  increased,  while  the  reduc- 
ing agent  is  often  absent. 

The  course  of  meningitis  varies  greatly  not  only  with  the  cause  but 
with  the  clinical  types  of  the  affection  and  the  severity  of  the  epidemic 
as  well.  Some  cases  are  mild  and  transient,  "abortive";  others  are  ex- 
tremely malignant,  "fulminant,"  in  nature,  ending  fatally  within  a  day 
or  two,  or  sooner.    The  mode  of  commencement  offers  no  certain  indica- 


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Fig.  176. — Fever  curve  of  tuberculous  meningitis  in  a  child  two  years  old. 

tion  as  to  the  ultimate  course.  As  previously  mentioned,  primary  men- 
ingitis begins  more  suddenly  and  progresses  more  rapidly  than  the  sec- 
ondary variety.  The  great  majority  of  cases  are  usually  ushered  in  bj'' 
profuse  vomiting,  rise  of  temperature,  severe  headache,  pain  in  the 
back  and  limbs,  sensitiveness  of  the  vertebral  column,  rigidity  and  con- 
vulsions. The  fontanelles  in  infants  are  distended,  the  bowels  confined, 
the  abdomen  retracted  (trough-shaped),  and  the  urine  scanty,  often  al- 
buminous. During  the  early  period  symptoms  of  excitement  of  func- 
tion prevail.  The  patient  is  delirious,  shrieks  (hydrocephalic  cry),  is 
very  sensitive  to  noises  and  light,  but  very  soon  he  passes  into  a  state  of 


DISEASES   OF   THE   NERVE   SYSTEM  613 

sopor  which  gradiiallj'  increases  in  intensity.  At  a  later  period  of  the 
disease  there  is  depression  of  function.  The  pulse  and  respiration  which 
in  the  beginning  are  accelerated,  later  become  irregular  and  slow,  the 
somnolence  deepens  to  coma,  and  various  paralyses  appear.  The  afore- 
mentioned eye  symptoms  are  usually  quite  marked  and  involvement  of 
the  facial  nerve  pronounced.  In  disease  of  the  base,  all  parts  of  the 
facial  nerve  may  be  involved ;  in  that  of  the  convexity,  only  the  lower 
part  may  suffer.  In  hopeless  cases  deglutition  also  becomes  affected ; 
the  coma  increases,  the  patient  can  no  longer  be  roused;  the  conjunc- 
tival reflex  is  abolished,  the  eyes  are  smeared  with  mucus  or  pus ;  the 
corneae  are  hazy  or  ulcerated;  the  sphincters  are  paralyzed;  and  after 
lingering  in  this  moribund  state  for  another  few  days  the  patient 
is  finally  relieved  of  the  agony  by  death.  Milder,  nontuberculous 
cases  may  gradually  recover.  In  this  event  the  disease  is  usually  fol- 
lowed by  very  slow  convalescence  and  frequently  by  deaf-mutism, 
aphasia,  amaurosis,  idiocy,  etc.  Meningitis  sometimes  runs  a  pro- 
tracted course,  continuing  for  weeks  wath  periods  of  marked  im- 
provement, but  finally  ends  fatally.  These  cases  generally  represent 
the  chronic  form  of  infantile  meningitis,  which  is  essentially  a  men- 
ingoencephalitis. 

Differential  Diagnosis 

In  the  early  stages  meningitis  may  be  confounded  with  typhoid  fever, 
pneumonia,  acute  exanthematous  diseases,  uremia  and  eclampsia  from 
other  causes.  In  typhoid  fever  the  vomiting  is  less  persistent,  diarrhea 
the  rule,  impairment  of  the  sensorium  less  marked  and  more  gradual  in 
development,  the  spleen  enlarged,  the  fever  characteristic  (step-curve), 
and  the  blood  responding  to  Widal's  reaction.  Apex  pneumonia  partic- 
ularly may  be  mistaken  for  acute  meningitis.  In  pneumonia  the 
"cerebral"  symptoms  often  clear  up  with  the  establishment  of  the  signs 
of  pulmonary  consolidation  or  develop  very  late  in  the  course  of  the  dis- 
ease, the  respiration  ratio  is  increased  and  expiration  is  prolonged,  and 
the  temperature  is  evenly  high.  On  the  other  hand,  in  meningitis,  the 
nervous  symptoms  increase  with  time,  respiration  is  irregular  or  ster- 
torous and  inspiration  prolonged  and  sighing,  and  the  temperature  va- 
riable. The  differentiation  between  meningitis  and  a  sudden  attack  of 
uremia  is  based  principally  upon  the  condition  of  the  urine  which 
should  always  be  tested  in  case  of  doubt.  The  history  also  is  very  help- 
ful. Eclampsia  caused  by  gastrointestinal  intoxication,  etc.,  or  develop- 
ing during  the  onset  of  some  febrile  disease  is  apt  to  be  mistaken  for 
meningitis  the  first  twenty-four  hours  only — until  the  alimentary  canal 


614  DISEASES   OF    CHILDREN 

has  been  emptied,  or  the  other  causes  of  the  eclampsia  have  become  ap- 
parent. 

Latent  tuberculous  meningitis  may  lead  to  many  errors  in  the  diag- 
nosis. It  may  be  confounded  with  severe  remittent  fever,  encephalitis, 
syphilitic  meningitis,  and  tumor  of  the  brain.  In  remittent  fever  the 
Plasmodium  malarias  or  pigment  is  readily  found  in  the  blood ;  encephal- 
itis can  be  excluded  by  the  absence  of  tubercle  bacillus  in  the  cerebro- 
spinal fluid ;  in  syphilitic  meningitis  there  are  other  evidences  of  syphilis 
(choroiditis,  rhagades,  spirochete,  etc.)  ;  in  tumor  of  the  hrain  the  prog- 
ress of  the  disease  is  slow,  and  there  are  permanent  focal  symptoms 
(localized  paralyses,  optic  neuritis,  etc.)  to  account  for  a  local  lesion. 
In  doubtful  cases  lumbar  puncture  and  the  tuberculin  reactions  will 
materially  aid  in  the  diagnosis. 

Bearing  in  mind  the  clinical  signs  and  the  findings  in  the  cerebro- 
spinal fluid  there  should  be  but  little  difficulty  in  differentiating  the 
usual  forms  of  meningitis  with  fair  precision — at  least  so  far  as  it  per- 
tains to  the  tuberculous  or  nontuberculous  variety.  Briefly  stated  the 
differential  symptoms  of  the  latter  types  are  as  follows: 

DIFFERENTIAL   DIAGNOSIS 
Tuberculous  Meningitis  Nontuberculous  Meningitis 

History:     Preceding  indisposition  Apparent    good    health;    infectious    dis- 
eases or  otitis 

Temperature:     Low  in  the  beginning  High 

MacEweu  's  sign :     Pronounced     ,  Slight 

Cerebrospinal      fluid:     Clear;      tubercle  Cloudy  or  purulent;  no  tubercle  bacilli; 

bacillus;     lymphocytosis      (mononu-  polynucleosis 

clear) 

The    eyes:     Optic   neuritis;    choroid   tu-  Absent 

bercles 

Skin  eruptions:     Indefinite  Frequently  petechias 

Paresis:     Early  and  variable  Late 

Von  Pirquet's  test:     Positive  Negative 
Complement -fixation   reaction :  *     Usually 

positive  Negative 

The  prognosis  at  best  is  very  grave.  Tuberculous  meningitis  is 
invariably  fatal.  The  mortality  in  nontuberculous  meningitis  ranges 
between  50  per  cent  and  75  per  cent.  Where  operative  procedures  can 
be  brought  into  use,  e.  g.,  traumatic  or  otic  meningitis  with  localized 
lesions,  the  outcome  is  more  hopeful,  provided  no  time  is  lost  and  the 
patient's  general  health  is  fair. 

Treatment. — Aside  from  operative  treatment  wherever  indicated, 
lumbar  puncture  for  the  relief  of  pressure  symptoms,  and  meningo- 
coccic  antitoxin,  little  need  be  expected  from  all  other  methods  of 

*See  p.  84. 


DISEASES   OF    THE    NERVE   SYSTEM  615 

treatment  in  vogue.  With  the  advance  in  our  baeteriologic  study  of 
the  cerebrospinal  fluid  and  the  possibility  of  early  detection  of  the 
etiologic  factor  of  the  meningitis  in  question,  there  is  reason  to  hope 
that  the  majority  of  cases  of  meningitis  will  be  combated  by  a  curative 
serum.  Wonderful  results  are  already  on  record  from  the  early  intra- 
spinal and  intravenous  use  of  antimeningococcic  serum  in  meningitis 
due  to  the  diplococcus  intracellularis.     (See  p.  78.) 

More  recently  some  clinicians  have  claimed  excellent  results  from 
the  introduction  of  Flexner's  serum  directly  into  the  lateral  ventricle 
of  the  brain,  after  withdrawing  the  inflammatory  exudate.  This  pro- 
cedure, of  course,  can  only  be  employed  in  infants,  where  the  ante- 
rior fontanelle  is  still  open.    (See  p.  209.) 

The  symptomatic  treatment  consists  of  warm  baths  wnth  or  with- 
out mustard  every  three  or  four  hours;  ice  bag  to  the  head,  bro- 
mides and  stronger  hypnotics  to  relieve  excessive  irritation ;  small  doses 
of  calomel  and  large  doses  of  sodium  iodide;  careful  nursing  (feed- 
ing by  mouth,  gavage*  or  per  rectum),  and  stimulation  as  necessity 
arises.  Special  attention  should  be  paid  to  cleanliness  of  the  mouth 
and  nasopharynx,  and  avoidance  of  decubitus. 

When  an  epidemic  prevails,  all  such  prophylactic  measures  should 
be  instituted  as  are  recommended  for  other  contagious  and  infectious 
diseases,  special  care  being  taken  to  disinfect  nasopharyngeal  dis- 
charges.   As  a  prophylactic  urotropin  also  may  be  tried. 

;^     Natrii  lodidi 
Nfitrii  Bromidi 
Aq.  Mentha;  Pip. 
Aq.  Destil. 
M. 
S. — One   teaspoonful  every  six  hours,   for  a   child 
three  years  old.     (Routine  treatment.) 
'^^     Hyoscin.  Hydrobromatis  gr.  i,£oo  to  gr.  i^qq 

S. — Ilypodermically,  for  a  child  three  to  six  years 
old,     (To  relieve  excessive  excitation.) 

Diplegia  Spastica  Infantilis 

(Congenital  Eigidity  of  the  Limbs,  Little's  Disease) 
The  nature  of  this  form  of  infantile  paralysis  is  still  obscure.  De- 
generative changes  have  frequently  been  found  in  the  pyramidal 
tracts  or  their  correlated  structures  of  the  encephalon.  But  whether 
they  are  the  results  of  early  antenatal  arrested  development  (poren- 
cephalia), intrauterine  brain  disease,  traumatism  during  labor  (embol- 


3  ss 

2.00 

3  i  ss 

6.00 

5iv 

15.00 

q.  s.  ad  f  B  ii 

60.00 

*By  introducing  through  the  nose  a  soft  rubber  catheter. 


616 


DISEASES   OF    CHILDREN 


ism  or  hemorrhage)  by  instruments  or  dystocia;  or  prematurity,  are 
questions  awaiting  a  correct  solution.  Some  cases  are  certainly  ac- 
quired. 

The  symptomatology  of  this  affection  is  sometimes  manifested  soon 
after  birth  and  sometimes  not  until  the  child  begins  to  walk.    One  of 


Fig.  177. — Diplegia  sjcislica  infantilis  in  a  l)al)y  eight  months  old  wlio  sustained 
cerebral  injuries  (with  hemorrhages)  during  obstetric  delivery.  Note  rigidity  of 
neck  and  extremities  (right  arm  is  contracted  and  right  leg  pressing  against  left 
one)  :  baby  is  unable  to  change  its  position  without  assistance.  Note  also  convergent 
strabismus  as  a  result  of  paralysis  of  the  N.  abducens. 


Fig.  178. — Little's  disease.     "Scissors-gait"  or  cross-legged  progression. 


DISEASES   OF    THE   NERVE   SYSTEM 


617 


the  earliest  symptoms  is  rigidity  of  the  limbs.  The  child  usually  lies 
motionless  (does  not  kick)  with  the  legs  pressed  against  each  other 
or  one  upon  the  other.  He  begins  to  walk  late  and  with  difficulty  or 
may  not  walk  at  all.  If  he  is  able  to  walk,  he  takes  short,  rigid  steps 
with  the  feet  in  tiptoe  position  (talipes  equinus)  and  the  knees  pressed 
closely  together,  or  crossing  each  other,  sometimes  half  running  so 
that  at  every  step  a  fall  seems  imminent.  The  rigidity  gradually 
grows  worse,  leads  to  fixed  deformities  and  extends  to  the  upper  ex- 
tremities and  even  the  trunk.  A  Z-shaped  deformity  is  often  observed 
in  the  hand  when  the  patient  attempts  to  use  it.    Early  in  the  disease 


Fig.  179. — Diplegia  spastica  infantilis  (Little's  Disease).  Noto  extreme  spasticity 
of  the  muscles  of  the  upper  and  lower  extremities,  and  inability  to  stand  erect  with- 
out support. 


the  deformities  disappear  during  sound  sleep  or  deep  anesthesia.  The 
knee  jerks  are  exaggerated,  ankle  clonus  is  generally  present,  atrophy 
is  slight  and  develops  late,  and  the  sphincters  are  normal.  The  major- 
ity of  cases  present  symptoms  of  defective  psychical  development  (up 
to  idiocy),  stammering,  nystagmus,  strabismus,  athetosis  and  epileptic 
convulsions.  "Where  the  latter  symptoms  prevail,  the  prognosis  is 
very  bad,  otherwise  it  is  not  absolutely  unfavorable. 


618  DISEASES   OF    CHILDREN 

Treatment. — Under  suitable  treatment  the  progress  of  the  disease 
may  be  arrested  and  a  partial  cure  effected.  The  treatment  consists 
of  stimulating  baths,  passive  motion,  educational  exercises,  massage 
and  galvanization,  and  immobilization  in  the  corrected  position  by 
suitable  braces  for  a  period  of  months.  If  this  fails,  we  may  resort 
to  tenotomy,  tenectomy,  •  tendon  transplantation,  partial  resection  of 
the  motor  nerves  (Stoffel's  operation),  and  resection  of  the  poste- 
rior nerve  roots  (Foerster's  operation),  followed  by  the  aforemen- 
tioned therapeutic  measures.  Antisyphilitic  medication  is  sometimes 
beneficial.  When  the  seat  of  the  lesion  in  the  brain  is  discovered 
early,  an  attempt  may  be  made  to  ameliorate  the  otherwise  hopeless 
conditions  by  trephining,  and  evacuation  of  blood  clots, — decompres- 
sion,— or  removal  of  tumors,  if  there  be  any.  Persistent  and  painstak- 
ing after-treatment  is  essential  to  success.    (See  p.  643.) 

The  differential  diagnosis  between  this  disease  and  polioencephalitis 
is  based  principally  upon  the  absence  in  Little's  disease  of  true  paraly- 
sis and  the  presence  of  the  characteristic,  jerky,  half -running,  spastic 
scissors-gait. 

Hemiplegia  Spastica  Infantilis 

(Spastic  Cerebral  Paralysis,  Polioencephalitis  Strumpell) 

The  exact  status  of  this  diseased  condition  is  still  unsettled.  Some 
authors  look  upon  it  as  an  irregular  type  of  encephalitis  (q.v.)  or  polio- 
encephalitis (see  ''Poliomj-elitis"). 

Anatomically,  after  abatement  of  the  acute  process  (which  consists 
of  inflammation,  hemorrhage,  embolism  and  thrombosis  in  the  gray 
motor  cortical  substance)  it  is,  manifested  by  sclerosis,  atrophy,  fatty 
or  cystic  degeneration  of  certain  portions  of  the  brain — of  several 
convolutions,  an  entire  lobe,  or  of  the  large  brain  ganglia  ("agenesis 
corticalis").  Not  rarely  the  pyramidal  tracts  down  to  the  medulla 
spinalis  exhibit  secondary  descending  degeneration. 

It  is  a  disease  of  early  childhood,  up  to  four  years  of  age,  and  usually 
develops  suddenly  (very  rarely  insidiously),  with  fever,  nausea, 
vomiting,  headache  and  convulsions,  or,  less  frequently  in  connection 
with  other  infectious  diseases,  such  as  exanthema,  pneumonia,  etc. 
After  subsidence  of  the  acute  symptoms  it  is  noticed  that  one-half  of  the 
body,  or  one  arm  or  one  leg  is  more  or  less  paralyzed.  The  affected 
elbow  hangs  close  to  the  body  and  the  arm  is  bent  to  the  ulnar  side, 
while  the  fingers  are  flexed  into  the  hollow  of  the  hand ;  the  foot  is 
often  distorted  in  an  equinovarus  position  with  the  great  toe  overex- 
tended at  right  angles  to  the  metatarsus.     The  patient  walks  practi- 


DISEASES   OP    THE    NERVE   SYSTEM 


619 


cally  on  the  toes  of  tlie  paralyzed  leg.  As  the  disease  progresses,  the 
affected  limbs  become  atrophied  and  contracted  and  the  hand  manifests  a 
great  tendency  to  athetotic  and  choreic  movements.  The  tendon  reflexes 
are  exaggerated  and  there  is  more  or  less  marked  muscular  rigidity. 
The  muscles  never  exhibit  reaction  of  degeneration.  Sensation  is  un- 
impaired. The  cranial  nerves  (facial  and  optic),  as  a  rule,  are 
involved,  but  not  to  a  great  extent.  Sometimes  there  are  also  dis- 
turbances of  speech  (as  a  result  of  involvement  of  the  hypoglossus), 
epilepsy,  and  mental  impairment  up  to  total  idiocy.     In  the  course  of 


Fig.  180. — Hemiplegia  spastica  infantilis,  by  some  authors  looked  upon  as  a 
"cerebral"  or  " encephalitie "  type  of  poliomyelitis  with  lesions  chiefly  in  the  motor 
area  of  the  cerebral  cortex.  Note  peculiar  position  of  the  right  leg  in  the  act  of 
walking  and  characteristic  "athetotic"  hand. 

time,  especially  under  suitable  treatment  (which  is  practically  the 
same  as  in  anterior  poliomyelitis)  the  paralysis,  atrophy  and  contrac- 
tures may  somewhat  improve  and,  in  mild  cases,  disappear  entirely; 
but  on  th«  whole  the  prognosis  is  bad.  The  patients  are  usually  help- 
less in  mind  and  bod}^,  are  very  prone  to  suffer  from  epilepsy  and. 


620 


DISEASES   OF    CHILDREN 


where  the  cerebral  symptoms  are  pronounced,  they  rarely  attain  the 
age  of  twenty  or  thirty  years. 

As  already  suggested,  this  form  of  polioencephalitis  may  be  mistaken 
for  atypical  encephalitis  or  anterior  poliomyelitis.  In  both  of  these 
affections,  especially  in  typical  poliomyelitis,  athetosis  and  spasticity 
of  the  extremities  (both  pathognomonic  symptoms  of  spastic  cerebral 
paralysis)  are  absent.  Furthermore,  in  poliomj-elitis  there  are  reaction 
of  degeneration  and  diminution  or  loss  of  tendon  reflexes — the  contrary 
being  the  case  in  the  disease  in  question.  This  disease  calls  for  further 
study  for  its  clarification. 

The    treatment    is    essentially    the    same    as    in    encephalitis,    q,  v. 

Encephalitis 

(Nonsuppurative,  Hemorrhagic,  Encephalitis) 

Acute  encephalitis  is  encountered  principally  in  young  children.  It 
may  be  primary  and  occur  either  sporadically  or  in  epidemic  form,  in 
the  latter  event  often  in  connection  with  epidemic  poliomyelitis. 


Fig.    181. — Left  hemiplegia   following   acute   encephalitis.      Note   drooping    of   left 
shoulder  and  dragging  of  left  leg  in  the  act  of  walking. 


DISEASES  OP   THE   NERVE  SYSTEM  621 

Secondary  encephalitis  usually  occurs  in  association  with  divers 
acute  infectious  diseases,  such  as  influenza,  diphtheria,  scarlatina, 
pneumonia,  pertussis,  etc. 

Any  portion  of  the  brain  and  medulla  may  be  the  seat  of  the  in- 
flammation, although  there  seems  to  be  a  predilection  for  the  gray 
substance  of  the  cortex.  The  changes  in  the  brain  consist  principally 
of  cellular  infiltration  of  the  vascular  walls,  perivascular  cellular 
exudation,  hemorrhage  and  thrombosis.  The  larger  foci  at  first  ap- 
pear red  and  soft  and  later  yellowish-white.  After  the  process  has 
run  its  course  the  affected  part  of  the  brain  usually  shows  marked 
atrophy  with  cicatricial  contraction. 

The  clinical  course  varies  with  the  seat  and  extent  of  the  brain 
lesion.  As  a  rule  it  begins  suddenly  with  nausea,  headache,  vomiting, 
high  fever  and  often  convulsions.  This  is  followed  by  stupor,  slow 
pulse,  Cheyne-Stokes'  breathing,  constant  deviation  of  the  eyes  to  one 
side ;  and  if  the  medulla  is  involved,  also  by  implication  of  some  cranial 
nerves,  e.  g.,  facial  and  hypoglossal.  In  infants  the  fontanelle  is  usually 
not  bulging.  As  a  rule  the  tendency  of  acute  encephalitis  is  towards 
recovery,  except  for  remaining  mono-  or  hemiplegia,  and  often  mental 
impairment  (see  Hemiplegia  Spastica  Infantilis,  p.  618). 

Treatment. — The  treatment  is  symptomatic.  Ice  bag  to  the  head, 
warm  baths,  bromides  and  liquid  nourishment.  Lumbar  puncture  is 
of  but  little  therapeutic  value. 

Acute  encephalitis  may  be  mistaken  for  acute  cerebrospinal  or  tu- 
berculous meningitis.  The  differential  diagnosis  must  be  based  prin- 
cipally upon  the  cytologic  findings  in  the  cerebrospinal  fluid  (see 
p.  611).  The  absence  of  bulging  of  the  fontanelles  in  infants  points 
strongly  against  meningitis,  more  especially  of  the  tuberculous  variety. 
For  its  differentiation  from  polioencephalitis  see  pp.  620,  639. 

Brain  Abscess 

(Encephalitis  Purulenta) 

Suppurative  encephalitis  most  frequently  develops  in  connection 
with  inflammatory  or  suppurative  processes  in  adjacent  structures, 
e.  g.,  the  eyes  (panophthalmitis),  the  nose  (caries  of  the  cribriform 
bone),  and  especially  the  ears  (mastoid  disease).  It  also  occurs  as  a 
result  of  traumatism,  foreign  bodies  in  the  brain,  pyemia,  pulmonary 
abscess  or  gangrene,  ulcerative  endocarditis  and  embolism. 

The  encephalitis  may  be  diffuse  or  circumscribed,  run  an  acute  or 
chronic  course.  The  classical  brain  abscess  is  the  chronic  variety. 
Pathologically,  this  term  should  be  limited  to  circumscribed  coUec- 


622  DISEASES   OF   CHILDREN 

tions  of  pus  in  the  brain  surrounded  by  a  yellowish-white,  rather 
dense,  newly  formed  membrane,  possessing  all  the  characteristics  of 
a  pyogenic  membrane.  It  is  not  to  be  confused  with  an  acute  brain 
abscess  in  which  definite  lines  of  demarcation  from  the  healthy  tissue 
are  absent.  Congruent  with  circumscribed  abscesses  of  other  portions 
of  the  body,  the  inner  layer  of  the  membrane  lining  the  pus  cavity  is 
formed  of  soft  granulation  tissue,  while  the  contiguous  structures 
are  edematous,  reddened  and  highly  vascular.  Brain  abscesses  may 
be  single  or  multiple,  and  if  multiple  and  of  long  duration  may  be- 
come confluent  and  attain  considerable  size.  The  pus  in  acute  abscess 
is  reddish  or  yellowish  in  color,  while  in  chronic  abscess  the  pus  has 
a  greenish-yellow  color  and  a  consistence  similar  to  synovial  fluid. 
It  is  acid  in  reaction.  Unless  contaminated  by  necrosis  of  the  bone 
or  foreign  bodies  the  pus  is  usually  odorless.  An  encapsulated  ab- 
scess after  remaining  stationary  for  a  considerable  time  shows  a  tend- 
ency to  extend,  not  gradually,  but  in  steps.  According  to  Bergmann, 
each  step  represents  a  new  inflammation,  and  at  autopsy  one  finds 
the  traces  of  a  recent  softening  adjacent  to  some  portion  of  an  older 
abscess  cavity.  Large  portions  of  the  brain  may  thus  be  destroyed, 
and  if  the  gray  matter  is  preserved,  an  abscess  may  extend  over  the 
whole  lobe  or  even  throughout  an  entire  hemisphere  without  produc- 
ing definite  symptoms  indicating  the  trouble.  The  meninges  rarely 
escape  involvement. 

The  clinical  picture  of  purulent  encephalitis  is  very  misleading  and 
varies  greatly  with  the  seat  and  extent  of  the  lesion  and  the  stage  of 
the  disease.  It  is  less  confusing  in  cases  of  cranial  traumatism,  but, 
even  in  as  severe  an  injury  as  fracture  of  the  skull,  the  cerebral  symp- 
toms may  be  so  vague  as  for  days  to  escape  notice.  The  onset  is 
usually  sudden  with,  nausea,  vomiting,  fever,  stupor,  and  convulsions. 
Older  children  complain  of  dizziness  and  headache.  This  condition 
may  last  one  or  two  days  or  as  many  weeks.  Then  either  the  coma 
increases  and  is  followed  by  death,  or  the  symptoms  abate,  and  the 
patient  is  apparently  on  the  road  to  recovery,  except  that  in  the 
majority  of  instances  monoplegia,  or  hemiplegia  with  or  without  in- 
volvement of  some  cranial  nerves  is  left  behind.  The  subsequent 
course  of  the  disease  depends  upon  the  nature  of  the  brain  lesion. 

Suppurative  encephalitis  of  very  limited  extent,  with  its  cause  re- 
moved, may  clear  up  without  appreciable  after  effects.  On  the  other 
hand,  where  an  encapsulated  abscess  has  formed,  the  violent  symptoms 
may  abate  and  the  acute  pass  into  a  chronic  stage.  This  state  reached, 
the  encephalitis  is  apt  to  run  a  very  protracted  course;  with  recurrent 
violent  exacerbations  and  deceptive  remissions;  on  the  one  hand,  giv- 


DISEASES   OP    THE    NERVE   SYSTEM  623 

ing  rise  to  symptoms  of  acute  meningitis;  on  the  other,  especially  if 
the  abscess  is  large  and  pressing  upon  the  motor  areas  and  cranial 
nerves,  to  those  of  tumor  of  the  brain.  In  either  case  the  diagnosis 
is  often  extremely  difficult.  Ordinarily  meningitis  differs  from  abscess 
in  that  it  pursues  a  more  acute  course,  and  the  brain  symptoms  are  in- 
dicative of  a  more  diffuse  lesion.  The  diagnosis  between  hrain  tumor 
and  abscess  is  much  more  difficult.  In  abscess  there  is  usually  an  ir- 
regular temperature  with  rigors,  motor  aphasia  and  paraphasia,  while 
in  tumor  fever  is  rare  and  there  is  a  greater  tendency  toward  disturb- 
ances in  the  area  of  distribution  of  the  cranial  nerves  at  the  base  of  the 
brain,  and  toward  choked  disc.  (See  "Brain  Tumor",  p.  645.)  A 
history  of  ear  disease  or  direct  violence  points  strongly  toward  abscess. 
Slowly  developing  focal  brain  symptoms  are  characteristic  of  brain 
tumor.  These  differential  points,  however,  at  best,  are  not  very  reli- 
able. 

As  previously  mentioned,  the  remissions  occurring  during  the  course 
of  chronic  brain  abscess  are  very  deceptive.  In  the  first  place,  the 
"latent  period"  is  rarely  entirely  free  from  signs  of  ill  health.  As 
a  rule,  the  patient  suffers  from  occasional  headache,  vomiting,  rise  of 
temperature,  mild  paresis,  etc.  Secondly,  there  is  no  way  of  telling 
when  in  the  midst  of  apparent  good  health  the  abscess  may  suddenly 
rupture  in  the  brain  ventricles  or  meninges  and  rapidly  end  fatally. 

Treatment. — The  prognosis  of  brain  abscess,  therefore,  is  always  very 
grave,  unless  surgical  interference  is  resorted  to  early.  The  operative 
results  are  especially  favorable  in  abscesses  due  to  otitis  or  trauma — 
provided  they  can  be  localized. 

Purulent  encephalitis  before  operation,  should  be  treated  by  perfect 
rest,  ice  bags  to  the  head,  lumbar  puncture,  etc. — the  same  as  acute 
meningitis. 

Early  prophylactic  measures,  especially  energetic  treatment  of  ear 
trouble,  scrupulous  attention  to  suppurative  conditions  of  the  eyes, 
nose  and  throat  are  all  powerful  in  the  prevention  of  the  dreadful 
complication  and  sequelae. 

To  emphasize  the  difficulty  encountered  in  diagnosing  chronic  brain 
abscess  even  under  the  most  modern  methods  of  observation,  I  may  re- 
late the  following  interesting  case : 

H.  D.,  aged  four  years,  27  lbs.  in  weight.  Family  history  good.  Parents  living 
and  well,  have  four  additional  healtliy  children.  Child  was  normal  at  birth,  breast 
fed,  and  free  from  any  serious  illness  until  tAVO  years  of  age,  when  he  had  an  attack 
of  measles,  apparently  mild  in  character.  One  year  later  he  began  to  complain  of 
headache  an(J  occasional  vomiting.  This  condition  continued  for  several  months, 
notwithstanding  careful  care  and  treatment,  and  a  stay  at  Mt.  Sinai  Hospital  for 


624  DISEASES  OP   CHILDREN 

ton  days.  He  came  under  our  observation  at  the  end  of  November.  We  made  a 
tentative  diagnosis  of  tuberculous  meningitis.  Admitted  to  the  Postgraduate  Hos- 
pital (H.  D.  Chapin's  service)  December  1st.  Temperature  for  following  week  ranged 
between  normal  and  half  a  degree  above,  pulse  between  70  and  92,  and  respiration  be- 
tween 24  and  28  per  minute.  Child  moaned  and  complained  of  headache.  Persistent 
projectile  vomiting,  especially  after  breakfast.  Staggering  gait,  ataxia  of  right  arm. 
Choked  disc  in  both  eyes,  more  marked  in  left.  Tuberculin  and  Wassermann  reactions 
negative.  The  same  result  of  examination  of  cerebrospinal  fluid  and  urine.  Blood 
shows  90  per  cent  hemoglobin,  5,392,000  erythrocytes,  24,000  leucocytes,  36  per  cent 
lymphocytes  and  64  per  cent  neutrophiles.  Eoentgen-ray  examination  discloses  the  fol- 
lowing picture:  Pituitary  fossa  enlarged  and  base  eroded;  glenoid  processes  atro- 
phied; also  atrophy  of  anterior  portion  of  vault — all  pointing  to  tumor  of  pituitary 
gland.  Operation,  January  5.  Escape  of  large  quantity  of  cloudy  fluid,  free  from 
tubercle  bacilli.  No  growth  about  cerebellum  and  nothing  found  after  incision  in 
right  lobe.  An  ulcerated  spot  about  Y2  inch  in  diameter  is  visible  on  superior  sur- 
face of  vermis.  Puncture  of  this  area  fails  to  bring  pus.  The  boy  promptly  recov- 
ered from  the  effects  of  the  operation  and  improved  for  about  ten  days.  Gradually 
grew  worse  thereafter;  developed  a  higher  temperature,  from  101°  to  105°  F.  and 
died  January  27.  Autopsy:  Large  ulcerated  area,  size  of  silver  dollar,  in  summit 
of  vermis,  purulent  collection  under  the  membrane  about  pons  and  crura.  Incision 
of  cerebellum  reveals  an  abscess  cavity  size  of  thumb  and  almost  l^/^  inches  in 
length,  occupying  the  right  lobe  and  extending  slightly  to  the  left  lobe.  Pus  shows 
no  bacteria  in  pure  culture. 

Whether  the  abscess  was  the  direct  result  of  the  measles  or  the  consecutive 
latent  otitis  could  not  be  determined. 

Lethargic  or  Epidemic  Encephalitis 
(Meningo-,  Encephalo-,  Myeloneuritis) 

Though  supposedly  of  very  recent  origin,  this  affection  has  undoubt- 
edly occurred  on  previous  occasions,  and  either  passed  unnoticed 
or  was  diagnosed  as  nonsuppurative  encephalitis  or  the  cerebral  type 
of  poliomyelitis,  with  both  of  which  diseases  it  has  several  symptoms  in 
common.  There  are  two  definite  records  which  substantiate  this  view. 
An  epidemic  of  "sleeping  sickness"  occurred  in  1712  in  Tiibingen 
(Germany)  and  its  vicinity.  The  other  record  refers  to  an  epidemic 
of  encephalitis  which  prevailed  in  1890  during  and  after  the  influenza 
epidemic  in  Austria-Hungary,  Italy  and  Switzerland,  and  was  then 
spoken  of  as  "Nona."  The  most  recent  epidemic  of  lethargic  encephali- 
tis dates  back  to  1916,  and  was  first  described  by  von  Economo  of  Vienna. 
Since  then  numerous  cases  have  appeared  in  divers  parts  of  Europe 
and  America,  following  the  trail  blazed  by  the  destructive  epidemics 
of  influenza,  justifying  the  assumption  either  that  this  affection  acts 
as  a  predisposing  cause  of  encephalitis,  or  that  the  same  infectious 
agent   forms  the   etiologic  factor  in  both   affections.     Von   Wiesner,^ 

iWien.  klin.  Wchnschr.,  p.  933,    1917. 


DISEASES   OF    THE   NERVE   SYSTEM  625 

J.  A.  Wilson,-  and  Strauss  and  Loewe^  present  evidence  to  the 
contrary,  yet,  until  further  preponderating  corroboration  has  been 
adduced,  the  question  of  the  exact  identity  of  the  causal  factor  is  best 
left  in  abeyance. 

Pathology. — Whatever  its  identity,  recent  observations  have  shed 
considerable  light  on  the  mode  of  activity  of  the  infectious  agent.  It 
has  been  shown  to  attack  the  central  and  peripheral  nervous  system 
and  its  coverings  in  a  very  Avidespread  manner.  The  structures  par- 
ticularly involved  are  those  about  the  third  ventricle,  the  acqueduct 
of  Sylvius,  the  lateral  ventricles  and  optic  thalamus,  and  the  pons  and 
medulla.  Occasionally  lesions  are  found  also  in  the  cortex  and  in  the 
cerebellum.  The  spinal  cord  also  is  subject  to  attack.  The  lesions  are 
of  an  inflammatory,  sometimes  hemorrhagic,  character,  and  occur  in 
nodular  and  diffuse  forms. 

Microscopically  we  find  thickening  of  the  leptomeninges  with  exu- 
dation or  vascular  congestion.  The  gray  matter  is  the  site  of  peri- 
vascular cellular  infiltration.  There  is  ample  evidence  of  toxic  de- 
generation of  the  nerve  cells  and  neuronophagy. 

Symptomatology. — The  symptoms  correspond,  of  course,  with  the 
functions  of  the  cerebrospinal  system  affected.  Thus,  if  the  lesion  is 
localized  in  the  globus  pallidus,  tremor  and  rigidity  result;  if  in  the 
thalamus :  choreiform  athetotic  movements ;  if  in  the  meninges :  rigidity ; 
if  in  the  spinal  cord :  neuritic  pain ;  if  in  the  cranial  nerve  nuclei :  facial 
paralysis,  ophthalmoplegia,  etc. ;  and  finally  if  the  cerebellum  is  attacked, 
ataxia  supervenes.  In  our  opinion  it  is  erroneous  to  speak  of  special 
types  of  the  disease,  as  the  symptomatology  may  at  any  moment 
undergo  considerable  modification  with  extension  or  retrogression  of 
the  inflammatory  process. 

In  children  the  onset  of  the  affection  is  rather  sudden,  with  rise  of 
temperature,  vomiting  and  more  rarely,  convulsions.  Sometimes  the 
attack  is  preceded  by  sore  throat,  lassitude,  and  headache.  The  fever 
usually  remains  moderate  during  the  entire  course  of  the  disease,  only 
exceptionally  reaching  104°  or  105°  F.  The  pulse  is  generally  rapid, 
and,  as  will  be  mentioned  later,  may  become  very  irregular.  About 
twenty-four  hours  after  the  onset  it  is  noticed  that  the  patient  is 
losing  interest  in  his  surroundings,  becomes  drowsy  and  apathetic, 
and,  as  time  goes  on,  the  lethargy  becomes  so  deep  and  continuous  as 
almost  to  resemble  a  state  of  coma.  Yet  with  some  effort  the  patient 
may  be  sufficiently  aroused  to  respond  to  questions  and  to  partake 
of  nourishment.     During  the  profound  lethargy  the  child's  face  as- 


*Quart.  Joirf.  Med.,  Oxford,  p.  88,  1918. 
"Jour.  A.  M.  A.,  p.  1373,  1920. 


626  DISEASES    OF    CHILDREN 

sumes  a  mask-like  appearance  (Parkinsonian);  it  is  pasty,  waxy  and 
motionless.  Some  children  are  disturbed  in  their  slumber  by  sharp 
pain  in  the  face,  arms  and  le<rs,  and  when  aroused  present  marked  choreic 
or  athetotic  movements  of  the  head  and  arms.  In  the  great  majority  of 
eases  there  is  more  or  less  pronounced  involvement  of  the  cranial 
nerves.  Most  common  by  far  is  oculomotor  and  abducens  paralysis, 
with  ptosis,  diplopia  and  ophthalmoplegia  externa  and  interna.  Next 
in  frequency  is  unilateral  or  bilateral  facial  paralysis.  More  rarely, 
the  glossopharyngeal  and  vagus  are  affected,  as  may  readily  be  deter- 
mined by  the  impairment  in  speech  and  difficult  deglutition,  respira- 
tory and  cardiac  arrhythmia,  hiccough,  etc.  In  a  number  of  cases, 
and  usually  late  in  the  course  of  the  disease,  rigidity  of  the  neck, 
Kernig's  and  Brudzinski's  signs  are  present,  and  where  the  motor 
areas  are  involved,  monoplegia,  hemiplegia  and  diplegia  supervene. 
Occasionally,  also,  anesthesias  and  paresthesias  and  spontaneous  muscle 
spasms  are  encountered. 

Diagnosis. — In  view  of  the  multiplicity  of  the  symptomatology  the 
diagnosis,  in  the  absence  of  an  epidemic,  presents  considerable  diffi- 
culty. Lethargic  encephalitis  may  be  mistaken  for  nonsuppurative 
encephalitis  (see  p.  620),  complicating  or  following  divers  acute  in- 
fectious diseases;  cerebrospinal  meningitis,  tuberculous  meningitis 
and  polioencephalitis.  Lethargic  encephalitis  is  characterized  by 
progressive  stupor,  early  involvement  of  the  cranial  nerves,  espe- 
cially the  oculomotor  (ptosis,  etc.)  ;  paralysis  of  the  extremities,  late 
if  at  all;  mask-like  face;  neuritic  pain  and  choreiform  movements  or 
tremors.  In  simple  encephalitis  the  cranial  nerves  are  affected  late, 
whereas  mono-  or  hemiplegia  appears  early ;  the  Parkinsonian  expression 
of  the  face,  the  choreic  movements  and  pain  are  usually  absent.  In 
cerebrospinal  meningitis  opisthotonos,  Kernig's  and  Brudzinski's 
signs  appear  early  and  are  very  marked,  and  there  are  several  other 
symptoms  in  meningitis  which  are  absent  in  lethargic  encephalitis. 
In  tuberculous  meningitis,  the  onset  is  usually  slow,  paralysis  and 
optic  neuritis  occur  early;  Babinski's  reflex  and  McEwen's  sign  are 
marked,  tubercle  bacilli  are  present  in  the  cerebrospinal  fluid  and 
there  are  in  addition  other  symptoms  of  acute  meningitis.  In  polio- 
encephalitis paralysis  of  the  extremities  appears  early,  while  the 
mask-like  face  and  profound  stupor  are  absent.  According  to  Barker, 
Cross  and  Irwin,*  a  cell  count  in  the  cerebrospinal  fluid  of  from  10  to 
100  small  mononuclears  along  with  a  positive  globulin  reaction,  a 
negative  Wassermann  and  absence  of  tubercle  bacilli  or  meningococci, 


»Ani.  Jour.  Med.   Sc,  March,   1920. 


DISEASES   OF   THE   NERVE   SYSTEM  627 

at  a  time  of  an  epidemic  of  encephalitis,  point  strongly  to  the  ex- 
istence of  this  disease. 

Prognosis. — As  a  rule,  the  course  of  the  disease  is  protracted,  ex- 
tending over  many  weeks,  although  occasionally  mild  as  well  as  se- 
vere cases  are  encoutered  which  are  on  the  road  to  recovery  in  a  few 
days.  On  the  other  hand,  fulminant  cases  of  epidemic  encephalitis 
are  met  with  which  may  end  fatally  in  but  a  few  hours.  The  death 
rate  is  lower  in  children  than  in  adults,  and  ranges  between  10  to 
20  per  cent.  Involvement  of  the  sphincters,  hyperpyrexia  and  pro- 
gressive stupor  are  of  grave  import ! 

Convalescence  is  usually  slow  and  occasionally  interrupted  by 
slight  relapses.  The  possibility  of  sequelae  in  the  form  of  mental 
deterioration  and  epilepsy,  should  not  be  lost  sight  of. 

Treatment. — Absolute  rest  to  body  and  mind  is  essential  during 
the  entire  course  of  the  disease.  Liquid  diet;  where  deglutition  is 
difficult  milk  and  broths  may  be  given  by  gavage,  with  a  catheter 
introduced  through  the  nose.  This  may  be  repeated  twice  or  thrice 
daily.  In  the  early  stages  I  believe  to  have  obtained  great  benefit 
from  wet  cups  applied  to  the  nape  of  the  neck.  From  4  to  6  ounces 
of  blood  is  withdraAvn  once  or  twice.  The  temperature  and  pain  are 
best  relieved  by  warm  baths,  with  or  without  mustard.  In  symptoms 
of  brain  pressure,  especially  where  several  cranial  nerves  are  involved, 
lumbar  puncture  is  quite  useful.  Netter*  recommends  the  induction 
of  a  fixation-abscess  by  a  subcutaneous  injection  of  1  c.c.  of  turpentine. 
Hexamethylenamine  is  worth  trying,  especially  in  the  early  stages  of  the 
disease. 

During  convalescence  prolonged  rest  and  quiet  preferably  in  the 
country.  Nutritious  diet.  Massage  and  hydrotherapy.  Hematinic 
tonics. 

Poliomyelitis  Anterior 

(Polioencephalitis,   Poliomyeloencephalitis,   Infantile  Paralysis) 
(Heine-Medin  Disease) 

Our  knowledge  of  poliomyelitis  has  been  slow  and  gradual  in  its 
evolution  notwithstanding  the  fact  that  two  score  or  more  epidemics! 
of  the   disease   have   offered  unusual  facilities   for   its   careful   study. 


•Bull,  de  r  Academie  de     Med.,  Vol.  83,  No.   13,  1920. 

tin  modern  times  the  following  great  epidemics  of  poliomyelitis  have  been  recorded.  In 
1905,  in  Norway  and  Sweden,  together  2000  cases.  In  1907  the  first  great  epidemic  occurred 
in  America,  2500  cases  being  reported  in  and  around  New  York.  In  1909  there  were  out- 
breaks in  various  parts  of  the  United  States  and  Cuba  with  a  total  of  2,343  cases.  In  1910 
an  epidemic 'of  infantile  paralysis  spread  almost  throughout  the  entire  country,  about  500 
ca'ses  occurring  in  the  District  of  Columbia,  Iowa,  Massachusetts,  Minnesota,  Indiana,  and 
Pennsylvania,  and  about  400  cases  in   Maryland,   New   Hampshire,   New   York,   Rhode   Island, 


628  DISEASES   OP   CHILDREN 

The  first  scientific  essay  on  the  subject  was  written  by  J.  Heine  in 
1840.  Herein  he  attributes  the  affection  to  a  lesion  in  the  spinal  cord. 
In  1851  Rilliez  and  Barthez  contested  this  view  and  designated  the 
disease  as  "Essential  Paralysis  of  Children."  In  another  contribu- 
tion on  the  subject,  in  1860,  Heine  reasserted  his  opinion,  but  failed 
to  meet  with  authoritative  support,  until,  in  1870,  JofProy  and  Charcot 
announced  that  they  found  distinct  changes  in  the  spinal  cord  con- 
sisting of  ''primary  involvement  of  the  ganglion  cells  leading  to  atro- 
phy." Thereupon  "Essential  Paralysis"  was  replaced  by  "Spinal 
Paralysis  in  Children,"  or,  in  short  "Infantile  Paralysis."  In  1872 
Duchenne  called  attention  to  the  loss  of  reaction  in  the  paralyzed 
muscles  to  the  faradic  current,  and  four  years  later  Erb  demonstrated 
absence  of  reaction  also  to  the  galvanic  current.  Our  knowledge  was 
further  advanced  by  Seeligmiiller  by  furnishing  an  instructive  con- 
tribution to  the  study  of  the  pathogenesis  of  the  contractures  and 
deformities  following  poliomyelitis.  All  the  while  every  trifling  ail- 
ment and  mishap  were  blamed  for  the  origin  of  the  disease  in  ques- 
tion; and  although  in  1884  Striimpell  suggested  that  an  infectious 
agent  must  play  an  active  role  in  the  causation  of  the  affection,  we 
still  note  that  as  late  as  the  year  1893  no  less  an  authority  than 
Gowers  relates  several  cases  of  poliomyelitis  which  he  thought  were 
due  to  catching  cold  from  sitting  on  wet  grass.  Medin  is  deserving 
the  credit  for  having  systematized  the  symptomatology  of  infantile 
paralysis — in  1890 — and  we  are  indebted  to  Wickman  for  developing 
— in  1907 — the  epidemiology  of  the  disease  and  for  classifying  it  into 
several  distinct  types.  Our  knowledge  of  the  etiology  of  poliomye- 
litis was  greatly  enhanced — in  1909 — by  Landsteiner,  Popper,  Flex- 
ner  and  Lewis,  who  demonstrated  experimentally  that  monkeys  are 


Virginia,  Washington  and  Wisconsin.  The  epidemic  of  1916  exceeded  all  previous  epidemics 
in  severity  as  well  as  in  the  number  of  cases,  in  New  York  State  alone  over  13,000  cases  hav- 
ing been  reported.  The  total  must  assuredly  have  been  much  larger,  since  a  great  many  mild 
and  so-called  abortive  cases  must  inevitably  have  escaped  attention.  A  large  number  of  cases 
have  recently  reappeared  in  Boston  and  vicinity  and  about  100  cases  in  New  York. 
POUOMYEUTIS  IN  BOSTON 


Total 

Total 

Non- 

resident 

Resident 

Massachusetts 

Week  Ending 

Cases 

Deaths 

Cases 

Deaths 

Cases 

Deaths 

Cases 

July   24,    1920 

1 

1 

0 

1 

1 

0 

4 

July  31,  1920 

8 

0 

2 

0 

6 

0 

10 

August  7,  1920 

5 

2 

0 

0 

5 

2 

5 

August  14,   1920 

15 

4 

2 

1 

13 

3 

16 

August  21,  1920 

13 

3 

6 

1 

7 

2 

25 

August  28,  1920 

14 

3 

3 

0 

11 

3 

26 

September  4,   1920 

22 

9 

7 

3 

IS 

6 

52 

September  11,   1920 

26 

3 

13 

2 

13 

1 

53 

September   18,   1920 

29 

4 

9 

2 

20 

2 

66 

September  25,   1920 

30 

4 

10 

3 

20 

1 

68 

October  2.   1920 

27 

3 

12 

2 

15 

1 

72 

October  9,   1920 

11 

1 

1 

0 

10 

1 

53 

October  16,  1920 

11 

3 

3 

1 

8 

2 

46 

Totals  212  40  68  16  144  24  496 


DISEASES   OF    THE   NERVE    SYSTEM  629 

susceptible  to  this  atfeetion,  and,  furthermore,  that  in  these  animals 
one  attack  of  paralysis  prevents  a  second  successful  inoculation;  in 
other  words,  it  produces  an  immunity  against  the  disease.  Further 
studies,  moreover,  established  the  fact  that  in  human  beings  also  one 
attack  immunizes  against  another  one,  and  that  the  serum  of  recov- 
ered monkeys  as  well  as  men  contains  a  specific  substance  which  is 
capable  of  neutralizing  the  virus  in  vitro.  This  neutralizing  agent 
was  shown  to  exist  also  in  the  blood  of  a  large  number  of  so-called 
al)ortive  cases. 

Etiology. — With  these  facts  in  view  an  entirely  new  light  was 
thrown  upon  the  mode  of  dissemination  of  the  disease,  since  it  be- 
came immediately  obvious  that  poliomyelitis,  like  so  many  other  com- 
municable affections,  is  transmitted  by  an  infective  agent  that  follows 
the  lines  of  human  contact  and  travel,  and  is  carried  not  only  by  the 
victims  of  the  disease,  but  by  virus-carriers  as  well.  Experimental 
and  clinical  evidence  is  gradually  accumulating  which  tends  to  show 
that  the  virus  of  poliomyelitis  enters  the  human  body  most  frequently, 
even  if  not  exclusively,  through  the  upper  respiratory  tract  and  is 
carried  to  the  cerebrospinal  system  by  means  of  the  lymphatics. 

Owing  to  the  not  infrequent  occurrence  of  paralysis  among  lower 
animals,  e.  g.,  chickens  and  dogs  ("distemper"),  some  authors  thought 
it  plausible  to  fasten  the  source  of  infection  to  this  agency,  but  careful 
investigations  undertaken  during  the  1916  epidemic  by  the  Federal  and 
States  Boards  of  Health,  with  the  assistance  of  expert  veterinarians,  ut- 
terly failed  to  substantiate  that  assumption.  Moreover,  it  was  con- 
clusively shown  that  in  fowl,  for  example,  the  paralysis  was  the  result 
of  peripheral  rather  than  central  nerve  lesions.  There  is  much  more 
scientific  basis  for  the  supposition  that  the  disease  may  be  conveyed  by 
flies,  since  it  has  been  repeatedly  demonstrated  by  Flexner  and  Clark 
among  others  that  the  common  house  fly  can  carry  the  virus  of  poliomye- 
litis in  a  living  and  actively  infectious  state  for  forty-eight  hours  or 
longer,  and  abounds  during  the  period  of  greatest  prevalence  of  the  dis- 
ease, i.  e.,  the  hot  summer  months.  Now,  if  we  accept  the  hypothesis  of 
transmission  of  poliomyelitis  by  insects,  more  especially  flies,  then  the 
probability  of  conveyance  of  the  disease  to  the  human  body  by  means 
of  food  contaminated  by  house  flies  and  the  like  holds  true  with  equal 
force.  Be  it  remembered,  the  virus  of  poliomyelitis  withstands  both 
low  degrees  of  cold  as  well  as  ordinary  degrees  of  heat  for  long  periods 
of  time,  and  when  enclosed  in  albuminous  matter  it  resists  drying  for 
several  weeks.  In  view  of  the  aforesaid  and  the  fact  that  the  greatest 
number  of  victims  of  the  affection  are  met  in  children  under  three  years 


630  DISEASES   OF   CHILDREN 

of  age*  whose  diet  consists  principally  of  milk,  this  article  of  food  must 
naturally  come  under  the  suspicion  of  being  the  purveyor  of  the  in- 
fectious agent  of  poliomyelitis.  Yet,  after  a  very  thorough  investigation 
of  the  subject  in  question,  the  Committee  of  the  Department  of  Health 
of  the  City  of  New  York  has  arrived  at  the  conclusion  that  food,  and 
milk  in  particular,  plays  no  part  in  the  transmission  of  the  disease. 
We  must  add,  hoAvever,  that  this  exhaustive  investigation  notwith- 
standing, we  would  err  greatly  in  ignoring  the  aforementioned  hy- 
pothesis so  far  as  prophylaxis  is  concerned,  at  least  until  such  time 
as  the  identity  of  the  infectious  agent  i^  definitely  established.  Un- 
fortunately thus  far  all  bacteriologic  researches  have  failed  to 
demonstrate  the  etiologic  factor  of  poliomyelitis  microscopically.  It 
is  therefore  generally  assumed  that  it  is  not  bacterial  in  character, 
but  belongs  to  the  group  of  the  so-called  ultramicroscopic  filtrable 
viruses.  Experimentally  it  has  been  shown  to  be  highly  resistant  to 
diverse  destructive  measures.  It  withstands  glycerination  for  long 
periods  of  time  and  is  not  affected  by  0.5  per  cent  of  carbolic  acid; 
it  is  but  slightly  influenced  by  freezing  at  2  to  -4°  C.  for  forty  days; 
the  virus  is  less  resistant  to  high  degrees  of  heat — it  can  be  destroyed 
by  a  temperature  of  from  45°  to  50°  C,  if  exposed  for  half  an  hour. 
It  can  be  destroyed  also  by  a  2  per  cent  solution  of  peroxide  of  hydro- 
gen, by  methol  and  by  corrosive  sublimate. 

Pathology. — During  the  last  two  decades,  particularly,  great  ad- 
vances have  been  made  in  the  study  of  the  morbid  anatomy  of  polio- 
myelitis. Whereas  originally  the  opinion  generally  prevailed  that 
the  lesions  of  this  affection  were  essentially  limited  to  the  anterior 
horns  of  the  spinal  cord,  it  is  now  definitely  settled  that  no  portion  of 
the  cerebrospinal  system  may  escape  involvement,  and,  moreover,  as 
is  the  case  of  other  grave  communicable  diseases,  the  lesions  are  fre- 
quently disseminated  throughout  various  other  structures  and  organs 
of  the  body.  Since  the  upper  nasal  cavities  are  in  direct  communica- 
tion with  the  meninges  by  means  of  the  lymphatics  w^hich  pass  out- 
ward with  the  filaments  of  the  olfactory  nerve,  and  since  the  earliest 
changes  are  noticeable  in  the  perivascular  lymph  spaces  of  the  blood 
vessels  of  the  leptomeninges,  it  seems  reasonable  to  conclude  that  the 
virus  enters  the  human  body  through  the  upper  respiratory  tract. 
Microscopically  the  meninges  are  usually  found  injected  and  edema- 

•Of  5,346  cases  of  poliomyelitis  tabulated  by  the  N.  Y.  City  Board  of  Health  durihg  the 
1916  epidemic,  the  age  incidence  was  as  follows: 

6  months   or  younger           192  cases  6  years  245  cases 

1  year                                        793  7  years  160 

2  years  1,398  8  years  127 

3  years  1,998  9  years                     78 

4  years                                      693  10  years                      56 

5  years                                    412  10  to  15  years         94 


DISEASES   OF    THE   NERVE   SYSTEM  631 

tous,  and  tlie  brain  and  cord  moist,  translucent  and  edematous.  The 
gray  matter  of  the  cord  is  also  swollen  and  projects  above  the  level 
of  the  white  matter.  JVIinute  hemorrhages  are  often  distinguishable  in 
both  the  gray  and  white  matter,  the  former  often  assuming  a  grayish- 
pink  hue.  The  cerebrospinal  fluid  is  but  little  increased.  IMicroscopi- 
cally  the  pathologic  process  is  found  to  consist  chiefly  of  a  cellular 
exudation,  hemorrhages  and  edema.  The  lesions  are  most  pronounced 
where  there  is  an  abundance  of  blood  vessels,  hence  in  the  cervical 
and  lumbar  enlargements,  more  particularly  in  the  anterior  horns  of 
the  cord  and  in  the  medulla.  "The  cellular  exudate  forms  a  sheath  ap- 
parently completely  surrounding  the  vessels  for  long  stretches  and  in 
places  the  cells  are  so  numerous  as  to  form  thick  collars  which  seem 
to  press  on  the  lumen  and  thus  exert  a  mechanical  effect  in  obstructing 
the  circulation"  (Peabody,  Draper  and  Dochez).  A  similar  mechani- 
cal as  well  as  toxic  action  is  progressing  in  the  intimal  lining  of  the 
blood  vessels,  the  conjoint  pressure  soon  leading  either  to  hemor- 
rhagic softening  or  anemia-pressure-necrosis  of  the  infiltrated  struc- 
tures and  gradual  replacement  of  the  ganglion  cells  by  cicatricial 
tissue.  Of  course,  this  terminal  pathologic  stage  is  usually  not  reached 
where  the  pressure  is  early  relieved  by  absorption  of  the  hemorrhage 
and  cellular  exudate ;  hence,  the  large  number  of  mild  and  so-called 
abortive  cases,  and  the  tendency  towards  spontaneous  recovery.  In 
recording  his  observations  on  human  and  experimental  poliomyelitis 
Howe  distinguishes  three  pathologic  types  of  the  disease  :  (1)  Cases  in 
which  the  lesions  are  limited  to  infiltration  of  the  pia  and  blood  ves- 
sels: the  mesodermic  tissue  type;  (2)  cases  in  which  the  main  feature 
is  degeneration  of  the  motor  cells  in  the  anterior  horn,  accompanied 
by  the  proliferation  of  neuroglia;  the  ectodermic  tissue  type;  and  (3) 
the  mixed  type.  The  first  group  represents  the  general  reaction  of 
the  organism  to  the  infection,  manifested  by  changes  in  the  central 
nervous  system  and  the  lymph  tissues. of  the  body.  In  the  second 
group  the  changes  in  the  central  nervous  system  of  man  are  poly- 
morphous. The  reaction  in  the  ganglion  cells  and  nuclei  allows  the 
recognition  of  no  less  than  eight  different  forms  in  the  degenerative 
process  consequent  to  the  poliomyelitis  infection.  The  mixed  type  is 
usually  encountered  in  human  poliomyelitis.  As  already  stated,  the 
virus  of  poliomyelitis  is  productive  also  of  extensive  pathologic 
changes  in  the  lymphoid  tissues  and  parenchymatous  organs.  Peyer's 
patches  and  some  of  the  mesenteric  glands  show  lesions  resembling 
those  observed  in  typhoid  fever.  The  superficial  glands  of  the  body, 
the  tonsils,  the  thymus  gland,  the  liver  and  occasionally  the  spleen 
are  considerably  enlarged.     The  affected  muscles  show  definite  signs 


632  DISEASES   OF    CHILDREN 

of  degeneration.  Some  of  their  fibers  disappear  entirely  and  others 
are  shrunken,  the  whole  limb  being  atrophied  as  a  result  thereof. 
Often  the  bones  participate  in  this  patliologic  process. 

Symptomatology  and  Course. — An  affection  based  upon  so  vast  and 
varied  morbid  anatomy  must  obviously  manifest  itself  by  an  equally 
as  complex  a  symptomatology,  ranging  between  that  of  simple,  local 
and  often  transient  paralysis,  and  general,  frequently  fatal,  toxemia. 
No  wonder  that  prior  to  our  full  understanding  of  its  pathology  al- 
most every  type  of  the  affection  was  described  as  a  separate  clinical 
entity,  a  disease  sui  generis.  For  that  matter  even  the  present  tend- 
ency to  classify  poliomyelitis  into  several  distinct  types  is  hardly 
justifiable  from  a  pathologic  point  of  view;  and  having  had  the  op- 
portunity to  observe  a  great  many  cases  during  the  last  two  epidemics 
and  at  other  times,  the  author  cannot  help  but  feel  that  no  one  classi- 
fication will  cover  all  cases  clinically.  Hence  our  reason  for  not  attempt- 
ing to  present  one. 

Initial  Stage. — After  an  incubation  period  lasting  from  three  to 
twelve  days,  and  towards  the  end  indicated  by  indefinite  symptoms 
of  ill  health,  such  as  slight  fatigue,  irritability  and  anorexia,  the  tem- 
perature all  at  once  rises,  up  to  104°  F.,  the  child  complains  of  ir- 
regular, muscular  pain,  headache  and  sore  throat  or  other  symptoms 
of  old  fashioned  grip  or  is  seized  with  an  attack  of  indigestion,  with 
diarrhea  and  sometimes  vomiting,  in  young  children  not  rarely  ac- 
companied by  convulsions.  Physical  examination  reveals  diffuse 
congestion  of  the  throat,  with  or  without  a  slight  grayish  deposit  upon 
the  tonsils,  slight  rigidity  of  the  neck,  especially  on  bending  the  head 
towards  the  sternum,  marked  paresthesia,  muscular  jerking  or  tre- 
mors, distinct  drowsiness,  and  irritability  when  disturbed.  The  mind 
is  usually  clear  even  in  grave  cases.  The  heart's  action  is  generally 
exaggerated,  even  when  the  fever  is  low.  These  symptoms  may  remain 
stationary  for  from  twenty-four  to  seventy-two  hours  and  then  show 
a  tendency  towards  spontaneous  abatement  {abortive  type)  or  get 
rapidly  worse — herald  the  advent  of  paralysis. 

Paralytic  Stage. — The  paralysis  usually  sets  in  insidiously,  is  often 
preceded  by  progressive  muscular  weakness  and  either  remains 
localized  or  swiftly  spreads  to  other  parts  of  the  body,  the  degree  of 
severity  and  extent  of  the  paralysis  depending,  of  course,  upon  the 
gravity  and  seat  of  the  lesion.  In  the  majority  of  cases,  especially 
during  mild  epidemics,  the  pathologic  process  is  limited  chiefly  to  the 
spinal  cord  {spinal  type).  In  this  event  the  paralysis  usually  involves 
the  extremities  alone,  or,  less  frequently,  the  neck,  abdomen,  spine  or 
chest  as  well.    The  paralysis  may  be  partial  or  total.     The  extremities 


DISEASES   OF    THE    NERVE   SYSTEM 


633 


are  usually  affected  in  the  following  order  of  frequency:  one  leg,  both 
legs,  one  arm,  both  arms,  one  leg  and  one  arm  on  opposite  sides  or  more 
rarely  on  the  same  side,  both  legs  and  one  arm,  both  legs  and  both  arms, 
and  both  arms  and  one  leg.  Occasionally  the  paralysis  remains  limited 
to  a  group  of  muscles  or  even  to  a  single  muscle,  e.  g.,  the  tibialis  anti- 
cus,  gastrocnemius,  or  deltoid,  and  is  not  rarely  overlooked  until  atrophy 
has  set  in.  When  the  muscles  of  the  neck  are  implicated,  the  child  is 
unable  to  hold  the  head  erect;  the  latter  drops  (neck  drop)  either  for- 


Fig.  182. — Poliomyelitis  "spinal 
type ; ' '  lesion  in  lumbar  enlargement ; 
atrophy  and  right  ' '  drop-foot. ' ' 


Fig.  183. — Poliomyelitis  ' '  spinal ' ' 
type;  lesion  in  cervical  enlargement; 
paralysis  of  upper  arm  as  well  as  right 
serratus  magnus,  "angel  wing"  de- 
formity of  right  scapula,  marked  mus- 
cular atrophy. 


ward  or  backward,  or  sways  from  side  to  side.  In  paralysis  of  the  ab- 
dominal muscles,  owing  to  active  intraabdominal  pressure  by  gases, 
there  is  ''ballooning"  of  the  affected  muscles  which  contrasts  strongly 
with  the  flatness  of  the  intact  muscles.  With  the  spinal  muscles  affected 
the  patient  shows  a  peculiar  clumsiness  in  turning  around  or  from  side 


634 


DISEASES   OF   CHILDREN 


to  side  while  lying  flat  on  his  back,  and  is  unable  to  assume  a  sitting 
posture  without  assistance.  This  paralysis  is  ordinarily  overlooked  un- 
til frank  scoliosis  has  made  its  appearance.  Sometimes  the  paralysis 
manifests  itself  in  stages,  at  intervals  of  several  hours,  so  much  so,  that 
occasionally  the  muscles  implicated  first  may  already  be  on  the  mend 
while  a  new  group  of  muscles  may  just  about  be  attacked.  Where  the 
lesions  are  limited  to  the  lower  neuron  the  parah'sis  is  flaccid  in  char- 
acter, the  tendon  reflexes  greatly  diminished  or  lost,  the  reaction  to  the 


Fig.  184. — Poliomyelitis  "spinal 
type ; ' '  lesion  in  cervical  and  dorsal  re- 
gions; partial  paralysis  of  the  muscles  of 
the  neck,  abdomen,  and  right  thigh 
(atrophy). 


Fig.  185. — Poliomyelitis  ' '  spinal 
type;"  lesion  in  cervical  enlargement; 
"neck  drop." 


faradic  current  lost,  while  that  to  the  galvanic  current  may  persist  for 
some  time.  Sensation  is  but  slightly  impaired.  There  is  no  tendency 
to  acute  decubitus. 

In  a  small  percentage  of  cases  the  paralysis,  beginning  with  the  lower 
extremities,  gradually  spreads  upward  (progressive  or  ascending  type), 


DISEASES   OF    THE   NERVE   SYSTEM  635 

resembling  Landry's  paralysis),  involves  the  upper  extremities,  the  ex- 
ternal muscles  of  respiration,  and  the  diaphragm,  if  the  lesion  reaches 
the  upper  part  of  the  cervical  cord.  In  this  event  exitus  may  take  place 
after  from  two  to  four  days  as  a  result  of  respiratory  failure.  On  the 
other  hand,  the  paralysis  may  start  in  the  arms  and  from  here  spread 
downwards    (descending  type,  resembling  transverse  myelitis)    to  the 


Fig.  1S6. — Poliomyelitis  affecting  the  Fig.        187. — Poliomyelitis       "bulbo- 

abdominal  muscles  giving  rise  to  "bal-  spinal  type;"  lesion  in  medulla;  paialy- 
looning"  of  the  abdomen,  sis  of  left  facial  nerve,  left  forearm  and 

left  leg. 

lower  extremities.  In  these  eases  we  usually  find  paralysis  of  the  vesical 
and  anal  sphincters,  giving  rise  to  urinary  retention  or  dribbling  and 
obstinate  constipation  or  incontinence  of  feces,  respectively. 

In  another  group  of  cases  the  inflammatory  process  extends  to  the 
medulla  (hulhospinal  type).    The  lesion  is  generally  unilateral,  excep- 


636 


DISEASES   OF   CHILDREN 


tionally  bilateral,  and  clinically  characterized  by  partial  or  total  paraly- 
sis of  some  of  the  cranial  nerves,  in  addition  to  the  manifestations  ob- 
served in  the  purely  spinal  variety  of  poliomyelitis.  As  a  rule,  the  facial 
and  abducens  are  affected,  less  frequently  the  glossopharyngeal  and 
vagus,  and  occasionally  also  the  hypoglossal  nerve,  in  which  event  the  pa- 
tient presents  not  only  facial  paralysis,  inward  strabismus,  and  more  or 
less  marked  respiratory  difficulties  (Cheyne-Stokes'  breathing,  cyanosis 


Fig.  188. — Poliomyelitis  "pontine"  or  "cerebral"  type;  lesions  in  pons,  medulla, 
and  spinal  cord;  paralysis  of  right  facial  nerve,  left  forearm  and  hand,  external 
respiratory  and  abdominal  muscles  and  right  leg. 


and  cardiac  arrhythmia),  but  also  disturbance  of  phonation  and  deglu- 
tition. These  cases  are  usually  very  grave,  nay,  often  fatal  within  a  few 
days.  In  the  absence  of  concomitant  paralysis. of  the  extremities  one  is 
apt  to  diagnose  laryngeal  diphtheria.  Indeed,  on  several  occasions  the 
author  was  invited  to  intubate  these  cases.  Where  the  cord  remains 
intact  and  the  lesion  localized  in  the  medulla  alone,  the  tendon  reactions 
are  usually  exaggerated,  the  limbs  more  or  less  rigid,  and  there  is  a 


DISEASES   OF   THE   NERVE  SYSTEM 


637 


distinct  tendency  towards  ataxia  {ataxic  type)*  Tlie  aforementioned 
symptoms  are  much  more  pronounced  where  the  pathologic  process  in- 
vades also  the  pons  {pontine  type),  and  the  condition  is  further  aggra- 
vated by  the  usual  concurrence  of  oculomotor  paralysis  which  may  lead 
to  complete  ophthalmoplegia,  and  cross  paralysis  or  hemiplegia  al- 
ternans. 

During  the  recent  epidemics  ample  evidence  was  brought  forth  to 


Fig.  189. — Same  case  as  Fig.  188  showing  also  high  degree  of  scoliosis. 

prove  that  the  so-called  primary  polioencephalitis  (Striimpell,  see  Hemi- 
plegia Spastica  Infantilis),  instead  of  being  a  distinct  clinical  entity,  is 
probably  a  cerebral  or  encephalitic  type  of  poliomyelitis.  As  is  well 
known,  this  type  of  the  disease  is  manifested  by  the  predominance  of 
meningeal  symptoms,  such  as  recurrent  explosive  vomiting,  convulsions, 
rigidity  of  the  neck  up  to  opisthotonos,  and  marked  stupor.     Kernig's 


*Some  authors  attribute  the  ataxia  to  a  lesion  in  the  cerebellum  ;   the  postmortem   findings, 
however,  do  not  substantiate  this  claim. 


638  DISEASES   OF   CHILDREN 

and  Brudzinski 's  signs  are  usually  inconstant  and  appear  late,  and  seem 
to  be  due  rather  to  the  resistance  on  the  part  of  the  child  to  the  painful 
flexion  of  the  spine.  After  a  day  or  two  partial  or  complete  spastic 
paralysis  of  one  or  several  extremities  supervenes,  not  rarely  accompan- 
ied by  involvement  of  the  facial  nerve.  In  some  cases  there  is  also 
marked  incoordination  of  the  extremities.  The  tendon  reactions  are 
usually  greatly  exaggerated. 

In  the  majority  of  cases  pain,  either  spontaneous  or  on  passive  mo- 
tion, forms  a  conspicuous  symptom  of  acute  poliomyelitis.  As  the  pain 
often  follows  the  course  of  the  nerves,  as  in  neuritis,  these  cases  are 
sometimes  grouped  in  a  separate  class — the  polyneuritic  type.  Accord- 
ing to  Lovett,  the  pain  and  tenderness  are  sometimes  marked  enough  to 
cause  the  paralysis  to  be  entirely  overlooked,  and  a  diagnosis  of  rheu- 
matism or  scurvy  to  be  made.  In  2  cases  under  our  observation  during 
the  last  epidemic  hip-joint  disease  was  diagnosticated. 

Prognosis. — As  already  stated  a  great  many  children  fail  to  survive 
the  acute  phase  of  the  affection.  The  mortality  seems  to  vary  with  the 
virulence  of  the  epidemic.  Thus,  whereas  in  the  Massachusetts  epi- 
demic (1907-10)  of  1,599  cases  only  125  died,  the  epidemic  of  1916  de- 
stroyed 3,310  young  lives  in  New  York  State  out  of  a  total  of  13,177 
victims  of  poliomyetitis.*  The  highest  death  rate,  about  63  per  cent, 
occurred  among  the  cases  in  which  the  lesions  extended  to  the  medulla 
and  pons,  most  frequently  either  as  a  result  of  respiratory  failure  in 
consequence  of  paralysis  of  the  respiratory  muscles,  or  secondarily  to 
complicating  bronchopneumonia.  Most  of  them,  about  80  per  cent, 
succumbed  during  the  first  week  of  the  onset  of  the  disease,  only  11 
per  cent  in  the  second  week,  3  to  4  per  cent  in  the  third  week  and  about 
five  per  cent  some  time  later,  as  a  result  of  exhaustion  and  complica- 
tions. The  highest  mortality  was  noted  in  children  under  five  or  over 
fifteen  years  of  age,  higher  among  males  than  females. 

Convalescent  Stage. — This  stage  starts  with  the  subsidence  of  the 
acute  symptoms,  such  as  pain  and  fever,  and  with  the  permanent  arrest 


•Movement  of  Cases,  Deaths  and  Fatality  Rates  from  Poliomyelitis  During  the 
Epidemic  of  1916  in  New  York  State,  by  MoNTiisf 

State  of  New  York                 New  York   City  Rest   of   State 

Fatality                                      Fatality  Fatality 

Month                                                      Rate  per                                     Rate  per  Rate  per 

100                                              100  100 

Cases       Deaths       Cases       Cases       Deaths        Cases  Cases    Deaths     Cases 

June 367              64        17.4              313              53        20.1  54             1         

July 4,011            895         22.3           3,443            779        22.6  568  116         20.4 

August 5,987         1,466        24.5            3,927        1,080        27.5  2,060  368         17.9 

September 1,992            628        31.5               985            364        37.0  1,007  264        26.2 

October 645            215         33.3               258            122        47.3  387  93         24.0 

November 135              40        29.6                 47              25         53.2  88  15         17.0 

December 40              20        50.0                 18              11        61.1  22  9        40.9 

Total 13,177        3,310        25.1            8,991        2,444        27.2  4,186  866        21.1 

tM.  Nicoll,  Jr.    (New  York  State  Med.  Jour.,   Vol.   xvii.  No.   6). 


DISEASES   OF    THE   NERVE   SYSTEM  639 

of  the  paralysis.  It  corresponds  with  the  stage  when  the  excessive 
exudate  in  the  brain  and  cord  is  getting  absorbed,  the  pressure  upon 
the  vital  structures  is  being  spontaneously  relieved  to  a  greater  or  less 
degree,  and  consequently  some  of  the  paralyzed  nerves  or  muscles  be- 
gin to  functionate.  The  degree  and  extent  of  the  initial  paralysis  is  no 
criterion  as  to  the  final  outcome  of  the  disease  as  a  whole.  The  author 
has  watched  many  children,  seemingly  in  a  hopeless  condition,  to  re- 
cover almost  completely,  and  vice  versa,  some  apparently  mild  local- 
ized paralyses  to  persist  for  life,  notwithstanding  most  scrupulous  and 
scientific  treatment.  The  muscles  that  fail  to  recover  within  about  ten 
days  after  the  acute  attack  promptly  begin  to  show  signs  of  atrophy 
(the  limb  is  flabby  cold  and  cyanotic).  Associated  with  the  atrophy 
is  reaction  of  degeneration.  The  response  of  nerve  and  muscle  to  the 
faradic  current  is  usually  lost,  while  the  galvanic  irritability  persists, 
sometimes  for  a  year  or  two  after  the  onset  of  the  affection.  Owing 
to  the  laxity  of  the  muscles  and  their  inability  to  hold  the  articular  ends 
of  the  bones  in  apposition,  the  joints  soon  become  the  seat  of  subluxa- 
tions. As  the  paralysis  continues,  the  trophic  changes  become  more 
and  more  marked — the  limbs  lose  their  shape,  often  look  like  mere  skin 
and  bone,  and  the  growth  of  the  bones  becomes  retarded.  Moreover, 
owing  to  the  activity  of  the  intact,  antagonistic  muscles,  sooner  or 
later  divers  deformities  make  their  appearance.  In  cases  where  all  the 
muscles  of  an  extremity  are  uniformly  involved,  the  limb  remains  free 
from  deformity,  but  is  limp  and  lifeless  and  hangs  attached  to  the 
trunk  like  an  artificial  limb. 

Permanent  Stage. — The  paralysis  may  be  looked  upon  as  permanent, 
if  the  case  fails  to  improve  after  two  years'  careful  treatment.  Reaction 
of  degeneration  of  the  nerves  and  muscles  is  usually  complete,  and  the 
deformities  (talipes,  scoliosis,  etc.)  are  fully  established.  The  deform- 
ities are  generally  less  pronounced  in  the  so-called  cerebral  type  of 
poliomyelitis. 

Diagnosis. — Typical,  spinal,  poliomyelitis  (i.  e.,  sudden,  more  or  less 
complete,  flaccid  paralysis  of  one  extremity  or  several  of  them,  or  of  a 
group  of  muscles  of  the  trunk,  preceded  by  moderate  fever  and  other 
symptoms  of  an  ordinary  cold  or  indigestion)  usually  presents  no  diag- 
nostic difficulties,  whether  or  not  it  is  met  with  during  the  prevalence  of 
an  epidemic.  If  pain  forms  a  conspicuous  symptom,  poliomyelitis  may 
in  the  initial  stage  be  mistaken  for  scurvy,  rheumatic  fever,  or  poly- 
neuritis. Now,  in  scurvy  we  generally  find  a  history  of  a  slow  onset ; 
tumefactions  along  the  long  bones,  ribs  and  the  bones  of  the  head ;  spongi- 
ness  and  finish,  hemorrhagic  discoloration  of  the  gums,  and  the  im- 
mobility of  the  extremities  is  due  to  fear  of  pain  and  tenderness  but  not 


640  DISEASES   OF   CHILDREN 

to  actual  paralysis.  This  latter  symptom  is  characteristic  also  of  rheuma- 
tism. Besides,  in  this  affection  the  pain  is  more  acute  and  localized  and 
usually  associated  with  some  swelling,  especially  about  the  joints.  Fur- 
thermore, rheumatic  fever  is  not  rarely  complicated  by  chorea  and  endo- 
or  pericarditis.  Polyneuritis  is  very  uncommon  in  young  children ;  as  a 
rule,  it  follows  metallic  poisoning  or  serious  infectious  diseases,  is  most  apt 
to  begin  with  the  extensor  muscles  of  the  hands  and  feet,  and  the  symmet- 
rical paralysis  does  not  recede  as  early  as  the  paralysis  of  poliomyelitis. 
During  an  epidemic  of  infantile  paralysis  diverse  tuberculous  and  trau- 
matic affections  of  the  bones  and  joints  frequently  lead  to  diagnostic 
errors;  however,  in  doubtful  cases  a  Roentgen-ray  examination  and 
tuberculin  test  wall  readily  clear  up  the  diagnosis.  Much  more  diffi- 
culty is  encountered  in  interpreting  correctly  the  other  types  of  polio- 
myelitis, more  especially  in  the  absence  of  an  epidemic.  Thus,  the 
pontine  and  cerebral  types  have  several  symptoms  in  common  with 
acute  meningitis  and  secondary  encephalitis.  But  on  closer  observa- 
tion it  will  usually  be  noted  that  stupor,  Kernig's  and  Brudzinski's 
signs  appear  earlier  than  in  poliomyelitis  and  are  also  more  marked 
and  more  constant.  On  the  other  hand,  the  paralysis  appears  earlier 
and  is  more  extensive,  as  a  rule,  in  poliomyelitis.  Furthermore,  sec- 
ondary encephalitis  follows  or  complicates  some  infectious  disease, 
e.  g.,  influenza,  pneumonia  or  scarlatina.  As  errors  in  the  diagnosis 
may  prove  instrumental  in  spreading  the  affection  to  all  others  coming 
in  contact  with  the  patient,  it  is  wise,  where  there  is  the  least  doubt,  to 
proceed  with  a  careful  examination  of  the  cerebrospinal  fluid.  Accord- 
ing to  Peabody,  Draper  and  Dochez,  who  have  made  an  exhaustive  study 
of  poliomyelitis,  the  cerebrospinal  fluid  taken  during  the  early  days  of 
the  disease,  and  especially  before  the  onset  of  the  paralysis,  as  a  rule, 
shows  an  increased  cell  count  with  a  low  or  normal  globulin  content. 
At  this  early  stage  the  polymorphonuclears  may  amount  to  90  per  cent 
of  the  total  cells.  Later,  however,  most  fluids  show  almost  exclusively  lym- 
phocytes and  large  mononuclear  cells.  After  the  first  two  weeks  the  cell 
count  usually  drops  to  normal,  or  nearly  normal,  and  there  is  frequently 
an  increase  in  the  globulin  content.  Analogous  changes  may  be  found 
in  the  spinal  fluid  of  abortive  cases.  All  fluids  examined  by  those 
authors  reduced  Fehling's  solution.  As  the  cerebrospinal  fluid  of 
poliomyelitis  greatly  resembles  that  of  tuberculous  meningitis,  it  is 
advisable  to  exclude  the  presence  of  tubercle  bacilli  in  the  former. 
Where  further  confirmation  of  the  diagnosis  becomes  necessary,  we 
may  resort  also  to  the  colloidal  gold  reaction  of  the  cerebrospinal 
fluid,  which  according  to  Felton  and  Maxcy  is  constant  and  positive 
in  the  acute  stage  of  poliomyelitis. 


DISEASES   OF    THE    NERVE    SYSTEM  641 

While  the  blood  picture  of  patients  suffering  from  poliomyelitis  is 
not  as  specific  as  the  spinal  fluid,  it  is  nevertheless  of  some  diagnostic 
value  if  taken  in  connection  with  other  available  evidence.  There  is 
usually  a  leucocytosis  of  from  15,000  to  30,000,  and  the  polymorphonu- 
clear cells  are  increased  at  the  expense  of  the  lymphocytes. 

For  the  differential  diagnosis  between  polioencephalitis  and  lethargic 
encephalitis  see  p.  625. 

Treatment. — Prophylaxis. — With  the  earliest  detection  of  suspicious 
signs  of  acute  poliomyelitis,  the  patient  should  be  promptly  isolated, 
and  handled  in  the  same  manner  as  other  communicable  diseases  (see 
p.  68).  During  an  epidemic,  vomiting,  fever,  headache,  diarrhea,  con- 
gestion of  the  throat,  rigidity  of  the  neck  and  drowsiness,  should  be 
looked  upon  as  suspicious  of  poliomj-elitis.  When  the  diagnosis  has 
been  confirmed  the  attendant  should  be  quarantined  together  with 
the  patient  for  about  three  weeks.  If  for  financial  reasons  this  proves 
impracticable,  it  is  advisable  to  remove  the  patient  to  a  suitable 
hospital.  All  discharges  from  the  mouth,  nose  and  throat  should  be 
received  on  cloths  or  toilet  paper  and  immediately  burned.  The  feces 
and  urine  should  be  disinfected  prior  to  their  disposal.  The  room  of 
the  patient  must  be  screened  to  keep  out  flies,  mosquitoes  and  other 
insects.  Before  lifting  the  quarantine,  the  clothing,  bedding,  utensils, 
etc.,  of  the  patient  should  be  disinfected,  and  the  sick-room  and  its 
contents  thoroughly  cleaned  and  aired.  All  those  known  to  have 
come  in  contact  with  the  patient  should  be  carefully  watched — for 
about  twelve  days — for  the  aforementioned  suspicious  signs  of  polio- 
myelitis, and  if  need  be,  promptly  isolated.  During  the  period  of  ob- 
servation children  should  not  be  permitted  to  attend  school  for  about 
two  weeks.  Cleansing  of  the  nose  and  throat  twice  daily  with  anti- 
septic solutions,  e.  g.,  dioxide  of  hydrogen  2  per  cent,  is  worth  trying, 
although  it  has  recently  been  shown  that  antiseptics  may  irritate  the 
nasal  mucous  membrane  and  render  it  more  susceptible  to  bacterial  in- 
vasion. We  may  try  also  the  internal  administration  of  hexamethylen- 
amine,  as  a  preventive  of  poliomyelitis,  since  it  has  been  proved  to  find 
its  way  in  the  cerebrospinal  fluid  and  to  exert  a  germicidal  effect.  From 
10  to  15  grains  daily,  in  divided  doses,  will  usually  suffice.  Whenever 
possible,  individuals  should  oecupy  beds  singly. 

Active  Treatment. — 1.  Acute  Phase. — Absolute  rest  and  quiet  to 
body  and  mind  is  essential  during  the  acute  course  of  the  disease. 
The  patient  should  be  kept  in  bed,  in  recumbent  posture,  for  about 
ten  days,  and  the  affected  limbs  immobilized,  even  after  apparent 
recession  pf  the  paralysis,  to  prevent  early  muscular  contractures  and 
deformities.     This  is  easily  accomplished  by  the  application  of  light 


042  DISEASES   OP   CHILDREN 

splints,  well  padded  with  wadding,  to  the  paralyzed  limbs.  The  feet 
should  be  supported  at  right  angles  to  the  legs,  and  in  cases  where 
the  spinal  muscles  are  involved,  it  is  best  to  put  the  patient  in  a  Brad- 
ford frame.  As  in  all  febrile  affections  the  diet  should  he  nutritious 
and  easily  digestible,  and  should  consist  of  broths,  boiled  milk,  fruit 
juices,  and  well-cooked  cereals.  Where  deglutition  is  difficult,  cautious 
feeding  by  stomach  tube  may  have  to  be  resorted  to. 

No  specific  has  thus  far  been  discovered  to  combat  poliomyelitis  in 
any  of  its  forms  or  stages.  Immune  serum,  supposedly  efficient  in 
preventing  or  arresting  the  progress  of  poliomyelitis  in  monkeys,  has 
as  yet  failed  to  show  any  appreciable  benefits  in  human  beings. 
Nevertheless,  for  want  of  more  effective  therapeutic  measures,  its  use 
should  be  encouraged,  especially  in  grave  cases.  If  utilized,  we  must 
be  sure  that  the  donor  is  free  from  syphilis.  The  serum  is  administered 
in  the  same  manner  as  antimeningitis  serum,  by  lumbar  puncture  and 
intravenously.  It  should  be  injected  on  three  successive  days  in  doses 
of  from  15  to  20  c.c.  The  serum  is  valuless  after  the  acute  stage.  In 
rare  cases  intraspinal  injection  of  serum  is  followed  by  a  reaction 
meningitis.  As  in  other  acute  cerebrospinal  affections,  lumbar  punc- 
ture is  a  sovereign  remedy  also  in  poliomyelitis,  where  symptoms  of 
brain  pressure  manifest  themselves.  It  may  be  employed  once  or 
twice  daily,  according  to  indications.  Of  medicinal  agents,  urotropin, 
sodium  salicylate  and  sodium  bromide,  of  each  from  3  to  5  grains 
every  four  hours  will  generally  be  found  useful.  Respiratory  and 
heart  failure  should  be  treated  with  oxygen  inhalations,  and  camphor 
and  strychnine  or  caffeine  hypodermically.  The  author  believes  that  bene- 
ficial results  are  obtained  from  the  administration  of  potassium  iodide, 
in  from  2  to  5  grain  doses  every  four  hours ;  he  assumes  that  the  iodides 
aid  in  the  absorption  of  the  cellular  exudation  and  thus  relieve  intra- 
spinal pressure.  Severe  headache  may  be  mitigated  by  an  ice  bag  to  the 
head.  High  fever  may  be  reduced  by  warm  baths,  which  are  also  indi- 
cated in  excessive  cerebral  irritation.  Subdural  injections  of  suprarenal 
solutions  have  thus  far  proved  of  no  material  benefit,  and  the  same  is 
true  of  intravenous  injections  of  salvarsan. 

2.  Convalescent  Stage. — After  subsidence  of  the  acute  symptoms 
and  complete  cessation  of  the  pain  and  tenderness,  an  inventory,  as 
it  were,  should  be  made  of  the  stationary  damage  to  the  nerves  and 
muscles  inflicted  by  the  highly  destructive  virus.  As  a  rule  paralysis 
in  some  form  is  left  behind.  Where  the  paralysis  is  partial  or  limited 
to  single  muscles,  the  "spring  balance  muscle  test"  may  have  to  be 
resorted  to,  to  determine  with  any  degree  of  exactitude,  how  much 
power  there  is  still  left  in  the  affected  muscles.    This  test,  by  the  way, 


DISEASES    OF    THE    NERVE    SYSTEM  643 

is  also  of  great  value  to  register  in  pounds,  at  certain  inter ^'als,  the 
gain  or  loss  in  muscular  strength  after  a  certain  method  of  treatment. 
The  concensus  of  opinion  of  the  profession  is  at  present  in  favor  of 
getting  the  patient  in  a  sitting  and,  if  possible,  in  an  upright  position 
as  soon  as  possible,  provided  the  paralysis  is  not  very  extensive.  Of 
course,  this  should  be  done  only  with  the  aid  of  suitable  braces,  to 
prevent  deformities.  Where  the  spinal  or  abdominal  muscles  are  im- 
plicated, support  should  be  furnished  by  means  of  an  accurately  fit- 
ting light  corset,  and  in  cases  where  the  lower  extremities  are  effected, 
the  so-called  caliper  splint  should  be  applied.  Where  the  glutei  are 
also  involved,  we  have  to  resort  to  a  walking  frame  and  light  crutches. 
In  paralysis  of  the  deltoid  the  arm  should  be  supported  in  a  sling, 
and  to  prevent  permanent  deformities  of  the  forearm,  the  latter  is 
put  in  a  well-padded  wire  splint.  The  less  burdensome  the  splints, 
etc.,  the  better.  Furthermore,  it  is  very  important  not  to  fatigue  the 
patient,  whatever  method  of  treatment  is  adopted. 

To  prevent  early  atrophy  and  to  improve  the  impoverished  circula- 
tion of  the  structures  involved,  massage,  including  vibration,  heat, 
electricity  and  muscle  training,  including  bath  exercises,  are  of  un- 
doubted therapeutic  value.  The  treatment  should  begin  after  the  pain 
and  tenderness,  spontaneous  as  well  as  on  passive  motion,  have  com- 
pletely ceased.  The  massage  should  be  gentle,  local  as  well  as  general, 
and  should  be  applied  once  or  twice  daily  for  about  twenty  minutes 
at  a  time.  Later,  the  massage  may  be  supplemented  by  light  vibratory 
muscular  stimulation.  The  patient  should  be  very  warmly  dressed, 
and  the  affected  limb  should  in  addition  be  exposed  daily,  for  ten 
minutes  at  a  time,  to  dry  heat  obtained  either  from  a  large  electric 
bulb  or  the  numerous  baking  apparatus  on  the  market.  The  benefits 
derived  from  the  use  of  electricity  have  been  grossly  exaggerated;  yet 
a  mild  faradic  and  galvanic  current,  applied  for  from  five  to  ten 
minutes  at  a  time,  every  other  day,  may  hasten  recovery  by  inducing 
mild  muscular  contractions,  by  improving  nutrition  and  promoting 
conduction  of  nerve  impulses.  Muscle  training  or  passive  and  active 
motion  corresponding  to  the  normal  muscular  action,  is  the  si7ie  qua 
non  in  the  restoration  of  the  muscular  functions,  but  it  requires  a  very 
thorough  familiarity  with  the  exact  powers  of  each  muscle  or  group  of 
muscles.  Otherwise  by  exercising  the  muscles  in  the  wrong  direction 
considerable  harm  will  be  done.  Bath  exercises  also  are  very  beneficial. 
It  will  sometimes  be  noted  that  where  patients  show  no  muscular  power 
in  an  extremity,  when  put  into  the  bath  they  are  able  to  demonstrate 
some  powier  in  those  muscles, — the  buoyancy  of  the  water  apparently 
overcoming  the  gravity  of  the  limb.    As  the  entire  cooperation  and  con- 


644  DISEASES    OP    CHILDREN 

centration  of  attention  of  the  patient  is  indispensable  to  its  successful 
performance,  muscle  training  is  only  applicable  in  cliildren  over  five 
years  of  age.  Furthermore,  this  mode  of  treatment  is  best  entrusted 
to  an  expert  in  this  line  of  work. 

A  number  of  clinicians  claim  to  have  obtained  excellent  results 
from  the  injection  of  strychnine  in  the  paralyzed  muscles.  This  treat- 
ment was  originally  recommended  by  Charcot.  He  administered, 
once  daily,  1/40  to  1/50  grain.  As  strychnine  in  small  doses  is  a  useful 
general  tonic,  it  can  do  no  harm  and  possibly  may  do  some  good.  It 
may  advantageously  be  combined  with  the  gh'cerophosphate  of  iron. 
General  supportive  treatment,  ample,  nutritious  food  and  fresh  out- 
door air  are  excellent  adjuvants  in  the  reestablishment  of  the  dor- 
mant bodily  functions. 

3.  Permanent  Stage. — If  after  giving  the  aforementioned  methods 
of  treatment  faithful  trial  without  any  appreciable  benefit  to  the  pa- 
tient, but  on  the  contrary  the  paralysis  persists  and  the  deformities 
become  fixed,  there  is  nothing  else  left  but  to  attempt  to  correct  the 
deformities  by  operative  procedures.  The  profession  is  not  agreed 
on  the  time  when  an  operation  becomes  indispensable.  Some  surgeons 
advise  waiting  tAvo  years,  others  twice  as  long  or  even  longer.  Hence 
it  is  best  to  leave  the  decision  of  this  important  question  to  the  good 
judgment  of  the  individual  surgeon.  As  to  the  choice  of  the  particu- 
lar operations,  R.  W.  Lovett  offers  the  following  suggestions: 

Talipes  Equinus. — Stretching,  tenotomy  of  the  tendo  Achillis,  if  the 
anterior  muscles  have  fair  power.  Transplantation  of  the  extensor  of 
the  great  toe  or  other  extensors  into  the  tarsal  bones,  anterior  silk  liga- 
ments with  or  without  tenotomy,  tenodesis,  arthrodesis. 

Talipes  Calcaneus. — Astragalectomy,  tenodesis,  arthrodesis. 

Talipes  Varus. — Transplantation  of  the  anterior  tibial,  when  that  is 
active,  to  the  outer  third  of  the  foot.  Silk  ligament  from  the  fibula  to 
the  cuboid ;  astragalectomy,  tenodesis,  arthrodesis. 

Talipes  Valgus. — Transplantation  of  one  of  the  peroneals  to  the 
inner  side  of  the  foot,  silk  ligaments  from  the  tibia  to  the  inner  side  of 
the  tarsus;  astragalectomy,  tenodesis,  arthrodesis. 

Flexed  Knee. — Stretching  or  open  division  of  the  hamstrings. 

Hyperextencled  Knee. — In  cases  where  the  quadriceps  is  paralyzed 
and  the  hamstrings  and  the  gastrocnemius  are  good,  transplantation  of 
one  or  two  hamstrings  into  the  tubercle  of  the  tibia. 

Knock-knee. — Supracondyloid  osteotomy  (Soutter's  operation). 

Flexed  Hip. — Fasciotomy,  if  severe. 

Dislocated  II ip. — Arthrodesis. 


DISEASES    OF    THE    NERVE    SYSTEM 


645 


Slioiddcr. — Dropping  of  the  arm  away  from  the  glenoid  cavity,  ar- 
throdesis of  the  joint,  silk  ligaments. 

In  cases  of  deltoid  paralysis  with  the  pectoralis  major  active,  the 
origin  of  the  latter  may  be  transplanted  into  the  spine  of  the  scapula. 

The  operations  on  the  forearm,  elbow  and  wrist  vary  greatly  in  in- 
dividual cases.  Arthrodesis  of  the  elbow  is  useful,  but  the  operation  is 
not  applicable  at  the  wrist  on  account  of  the  nature  of  the  joint. 

Scoliosis. — Treated  in  the  same  manner  as  scoliosis  due  to  other 
causes  than  poliomyelitis. 

It  is  essential  to  the  success  of  these  operations  to  select  a  surgeon 
who  is  thoroughly  familiar  with  this  work.  But  even  in  the  best  hands, 
the  results  are  not  invariably  good.  This  is  especially  true  of  cases 
which  have  been  greatly  neglected  or  treated  by  the  numerous  quacks 
who  thrive  upon  the  ignorance  of  the  unfortunate  people. 

Tumors  of  the  Brain 

Of  the  total  number  of  cases  of  brain  tumors  on  record  about  one- 
half  occurred  in  children.  It  is  more  common  in  boys  than  in  girls. 
The  usual  seat  is  in  the  cerebellum  and  the  basal  ganglia.     Brain  tu- 


Fig.  190. — Secondary  passive  hydrocephalus  in  tumor  of  the  brain.     (O.  Vierodt, 
Pfaundler  and  Schlossmann^) 

bercle  is  especially  common,  and  relatively  frequent  also  are  divers 
forms  of  sarcoma  (gliosarcoma).  These  are  often  metastatic.  Hidden 
as  intracranial  neoplasms  are  from  sight  and  touch,  their  nature  must 
necessarily  be  a  matter  of  conjecture  only,  except,  perhaps,  in  cases 
of  bony  growths,  which  may  be  diagnosed  by  means  of  the  Roentgen- 
ray,  and  tubercle  and  sj-philis  which  may  be  surmised  by  the  presence 
of  other  tuberculous  or  syphilitic  lesions  in  other  parts  of  the  body  or 
detected  by  the  tuberculin,  complement  fixation,  or  Wassermann  tests. 


646  DISEASES    OF    CHILDREN 

The  diagnosis  of  brain  tumor  is  based  upon  the  general  and  local 
nerve  disturbances  they  produce.  As  a  rule,  the  general  symptoms 
precede  the  local,  and  consist  of  headache,  vomiting,  vertigo,  optic 
neuritis,  and  convulsions. 

The  headache  is  usually  persistent,  but  may  also  be  periodical,  sug- 
gesting a  malarial  origin..  The  headache  may  be  frontal,  vertical  or 
occipital,  or  equally  distributed  over  all  parts  of  the  cranium.  The 
locality  of  the  pain  occasionally  bears  a  direct  relation  to  the  seat  of 
the  tumor,  thus,  when  the  growth  is  in  the  white  substance  the  pain 
is  usually  frontal;  when  beneath  the  tentorium,  occipital,  etc.  The 
same  rule  often  applies  to  the  pain  elicited  on  tapping  the  skull  over 
the  seat  of  the  disease.  Intense  headache  in  infants  is  indicated  by 
rolling  of  the  head  from  side  to  side,  by  throwing  up  the  hands  to  the 
head,  contraction  of  the  eyebrows,  and  intolerance  to  light.  The 
headache  is  frequently  followed  but  may  also  be  preceded  by  vomit- 
ing. 

The  vomiting  is  projectile  in  character,  and  comes  on  suddenly. 
It  differs  from  gastric  vomiting  by  the  absence  of  other  signs  of 
stomach  trouble,  and  from  vomiting  accompanying  migraine  by  that 
the  headache  does  not  always  terminate  with  it.  Vomiting  is  espe- 
cially characteristic  of  tumor  in  the  medulla  oblongata  or  the  middle 
lobe  of  the  cerebellum,  but  it  may  occur  in  tumors  affecting  any  part 
of  the  brain. 

The  vertigo  may  be  constant  or  paroxysmal  and  is  most  marked  in 
affections  of  the  pons  or  cerebellum.  Vertigo  in  infants  frequently 
escapes  notice.  It  is  manifested  by  sudden  drooping  of  the  head,  pal- 
lor of  the  face  and  occasionally  also  vomiting. 

Optic  neuritis  sometimes  forms  one  of  the  earliest  symptoms  of 
brain  tumors.  It  does  not  always  correspond  to  the  size  of  the  tumor. 
The  choked  disc  is  usually  bilateral.  It  may  develop  slowly  or  rap- 
idly, and  in  either  case  the  optic  neuritis  proceeds  to  complete  optic 
atrophy. 

The  child's  nervous  system  being  highly  susceptible  to  irritation, 
increased  intracranial  pressure  is  quite  early  productive  of  convul- 
sions of  var^nng  severity.  The  convulsions  may  be  general  or  local. 
General  convulsions  with  loss  of  consciousness  may  occur  in  tumors 
of  any  part  of  the  brain,  but  are  more  common  in  tumors  of  the 
posterior  fossa  than  in  those  of  the  anterior  or  middle  fossa.  Local 
convulsive  seizures  are  met  with  chiefly  when  the  neoplasm  occupies 
certain  situations.  For  example,  convulsions  beginning  in  the  foot, 
as  a  rule,  are  indicative  of  the  lesion  being  in  the  upper  region  of  the 
motor  area;  those  of  the  arm,  the  middle  region;  and  those  of  the 


DISEASES    OF    THE    NERVE    SYSTEM  647 

face,  the  lower  region.  It  should  be  remembered,  however,  that  the 
effects  of  a  tumor  may  extend  far  beyond  its  actual  site,  and,  further- 
more, as  the  case  proceeds,  convulsions,  which  from  the  outset  have 
been  local,  may  become  general.  The  convulsive  attacks  may  recur 
frequently  and  last  from  several  seconds  to  as  many  hours.  The  con- 
vulsions are  not  rarely  followed  by  paresis  or  paralysis  of  the  affected 
limbs.  At  first  the  muscular  weakness  may  be  transient,  but  as  the 
disease  advances  it  becomes  permanent. 

The  focal  symptoms  of  brain  tumors  are  also  manifested  by  uni- 
or  bilateral  hemiplegia,  monoplegia,  affections  of  speech,  and  paraly- 
sis of  cranial  nerves.  (See  "Brain  Localization"  p.  602.)  The  local 
symptoms  pointing  to  the  seat  of  the  tumor  attain  their  greatest  preci- 
sion when  the  swelling — be  it  a  new  growth  or  an  inflammatory  mass — 
is  seated  in  the  motor  area  of  the  cortex.  They  do  not  always  correspond, 
however,  to  the  size  of  the  tumor.  Furthermore,  as  the  brain  usually  ac- 
commodates itself  gradually  to  the  increasing  pressure  and  functional  in- 
terference produced  by  the  new  growths,  the  appearance  of  the  focal 
symptoms  is  frequently  delayed  until  a  very  late  stage  of  the  disease. 
Once  established,  local  symptoms  are  of  great  help  in  arriving  at  a  correct 
diagnosis,  except,  perhaps  in  cases  Avhere  the  tumor  is  multiple  and 
distributed  through  various  parts  of  the  brain.  (See  ''Tuberculosis 
of  the  Brain,"  p.  452.) 

Diagnosis. — With  the  determination  of  the  seat  of  the  tumor,  the  diag- 
nosis is  greatly  facilitated  but  rarely  entirely  settled.  Brain  tumors  have 
several  symptoms  in  common  with  tuberculous  and  syphilitic  men- 
ingitis, brain  abscess,  epilepsy  and  hysteria.  The  differentiation  be- 
tween tuberculous  and  syphilitic  tumors,  and  chronic  tuberculous  and 
syphilitic  meningitis  is  extremely  difficult  and  often  impossible  espe- 
cially when  the  tumors  are  multiple.  In  tutercle  and  gumma  the 
symptoms  are  more  gradual  in  development,  the  optic  atrophy  more 
pronounced,  and  the  focal  symptoms  more  marked  and  localized, 
while  the  course  of  tuberculous  or  syphilitic  meningitis  is  much  more 
rapid  and,  besides,  there  are  several  other  symptoms  pathognomonic  of 
meningitis.  In  doubtful  cases  some  valuable  information  may  be  ob- 
tained from  the  tuberculin  and  Wassermann  tests  and  from  a  careful 
examination  of  the  cerebrospinal  fluid.  In  acute  'brain  abscess  optic 
atrophy  is  absent,  there  is  usually  a  history  of  acute  infection,  ear  dis- 
ease, or  trauma,  and  the  symptoms  of  purulent  encephalitis,  such  as 
chills,  fever,  stupor,  etc.  In  the  absence  of  this  history  there  is  practi- 
cally no  way  of  distinguishing  latent  chronic  abscess  from  tumor,  as  has 
already  been  emphasized  on  a  previous  occasion  (p.  623). 


648  DISEASES   OF    CHILDREN 

Jacksonian  epilepsy  may  resemble  brain  tumor  in  its  early  stage, 
but  as  the  disease  advances  the  diagnosis  can  readily  be  cleared  up 
by  the  absence  of  optic  neuritis  and  other  focal  symptoms.  There  are 
eases  on  record  of  hysterical  hemiplegia  with  convulsions  and  contrac- 
tures which  were  mistaken  for  brain  tumor.  Careful  investigation,  how- 
ever, will  usually  reveal  the  absence  of  optic  neuritis,  and  the  fact  that 
in  hysteria  the  symptoms  are  inconstant  and  multifarious,  rather  sud- 
den in  development,  and  rarely  progressive  in  character. 

The  nature  of  the  tumor  can  sometimes  be  established  by  its  seat. 
Thus,  if  the  tumor  is  located  in  the  cerebellum  or  pons,  it  is  probably 
tubercle  or  glioma ;  if  in  the  cortex,  it  is  apt  to  be  syphilitic.  Cysti- 
cerci  are  most  commonly  met  with  in  the  meninges  or  cortex.  Abscesses 
are  usually  situated  in  the  cerebral  or  cerebellar  *' hemisphere,"  and 
but  rarely  in  the  central  ganglia,  the  pons,  medulla,  or  the  middle 
lobe  of  the  cerebellum.  Too  much  reliance,  however,  cannot  be  placed 
upon  these  observations. 

Treatment. — In  view  of  the  possibility  of  the  tumor  being  syphilitic,  it 
is  always  advisable  to  put  the  patient  on  an  active  antisyphilitic  course  of 
treatment  (the  iodides  and  mercury).  In  syphilitic  disease  prompt 
treatment  will  soon  be  followed  by  amelioration  of  the  symptoms,  and, 
if  faithfully  persisted  in,  often  by  a  cure.  This  therapeutic  measure 
is  occasionally  attended  by  favorable  results  also  in  growths  other 
than  syphilitic,  and  should,  therefore,  be  resorted  to  as  a  routine 
procedure  in  all  obscure  brain  lesions.  Antisyphilitic  treatment  prov- 
ing negative,  and  tonics,  in  the  form  of  fresh  air,  generous  diet,  cod 
liver  oil,  iron  and  the  hypophosphites,  failing  to  benefit  the  patient, — 
tonic  treatment  may  do  well  in  tubercle,  and  if  employed  early  may  in  ex- 
ceptional cases  arrest  its  growth, — the  question  of  surgical  interfer- 
ence should  be  taken  under  advisement.  An  operation  is  indicated 
where  the  tumor  is  single,  and  situated  superficially  in  a  part  of  the 
brain  (motor  area  of  the  cortex)  which  can  be  reached  and  from 
which  the  tumor  can  be  removed  without  immediate  danger  to  life. 
Under  favorable  conditions,  an  operation  should  be  performed  early, 
before  the  general  health  has  greatly  suffered  and  permanent  injury 
has  resulted  to  organs  and  limbs  from  persistent  brain  pressure.  Re- 
cently successful  attempts  have  been  made  to  remove  growths  from 
deeply  seated  structures;  the  results  as  to  life  and  good  health,  how- 
ever, are  still  too  few  and  too  far  between  to  warrant  precipitate  action. 

In  hopeless  cases  morphine  and  its  derivatives  will  help  to  relieve 
the  agony.     (For  "Tumors  of  the  Pituitary  Gland,"  see  p.  570.) 


DISEASES    OF    THE   NERVE   SYSTEM  649 

Epilepsia 

(Epilepsy;  Fits) 

Epilepsy  is  an  obscure  affection  of  the  brain,  in  typical  form  char- 
acterized by  attacks  of  loss  of  consciousness,  local  or  general  con- 
vulsions, and  a  great  tendency  toward  psychic  disturbances.  The 
situation  and  exact  nature  of  the  brain  lesion  is  still  undetermined, 
but,  judging  from  the  pathologic  alterations  (atrophy,  hypertrophy, 
abscess  formation,  sclerosis,  porencephalia,  retention  of  subcortical 
cells,  changes  in  the  blood,  etc.)  so  frequently  found  postmortem, 
there  is  reason  to  believe  that  there  is  no  one  pathologic  entity  re- 
sponsible for  the  morbid  condition. 

The  causes  of  epilepsy  are  many  and  divers.  Congenital  defects  of 
the  brain  or  skull;  traumatism  to  the  brain  or  skull  (during  birth  or 
after)  ;  infectious  diseases  affecting  the  brain  directly  or  indirectly ; 
toxemias  of  all  kinds,  including  grave  gastrointestinal  intoxication ; 
repeated  attacks  of  convulsions  from  reflex  causes;  neoplasms,  in- 
cluding syphilitic  and  tuberculous ;  sudden  psychic  disturbances,  such 
as  sudden  shock,  etc.,  among  many  other  as  yet  obscure  causes,  all 
contribute  their  share  toward  development  of  epilepsy  at  some  period 
of  life.  An  hereditary  disposition  is  traceable  in  a  certain  number 
of  cases,  and  children  of  syphilitic,  alcoholic,  and  neurotic  parents 
are  more  prone  to  contract  the  affection  than  those  free  from  such 
encumbrances. 

No  age  is  exempt  from  the  disease,  but  it  is  most  apt  to  develop  in 
children  of  from  two  to  fifteen  years  old. 

The  exact  time  of  the  beginning  of  the  disease  cannot  always  be 
traced,  since  the  symptoms  may  be  so  mild  as  to  escape  observation. 
The  child  may  for  a  few  moments  ''hang  its  head,"  turn  pale,  and  the 
paroxysm  would  be  over  with — hardly  any  reason  to  suspect  epilepsy. 
The  little  attack  may  not  recur  for  weeks  or  months,  so  that  the  last 
one  is  long  forgotten  when  the  next  one  sets  in.  It  is  only  after  the  at- 
tacks grow  longer  in  duration,  stronger,  more  frequent,  are  preceded 
by  an  aura  and  possibly  followed  by  involuntary  urination  and  de- 
fecation, and  profound  sleep,  that  the  nature  of  the  dreadful  condi- 
tion is  fully  realized. 

Genuine  epilepsy  varies  greatly  in  severity  not  only  in  different 
individuals  but  also  at  different  times.  In  addition  to  the  rudimen- 
tary forms  later  to  be  described,  the  paroxysms  are  generally  classi- 
fied into  severe  {grand  mal),  mild  {petit  mat),  and  cortical  or  Jack- 
sonian.  The  attacks  are  frequently  preceded  by  a  warning  {aura)  of 
motor,  sensory  or  vasomotor  character.    There  may  be  slight  twitchings 


650  DISEASES    OF    CHILDREN 

of  the  limbs,  eyes,  or  head,  slight  general  tremor,  a  vague  sensation  in 
the  stomach,  a  feeling  of  numbness  or  pricking  in  the  extremities,  hear- 
ing of  noises,  seeing  of  colors  or  sparks,  smelling  of  peculiar  odors, 
irritability,  hallucinations,  etc. 

In  grand  mal  immediately  following  the  aura,  and  also  without 
it,  the  patient,  who  may  appear  to  be  in  good  health,  suddenly  cries 
out,  loses  consciousness  and  falls,  and  becomes  fixed  in  a  tonic  spasm, 
with  face  and  limbs  contorted  and  breathing  suspended.  His  face  is 
pale  or  cyanotic;  his  eyes  are  widely  open  (pupils  usually  dilated) 
and  staring  or  rolled  upward  or  sideward.  The  teeth  are  pressed 
firmly  together,  with  the  tongue  often  impacted  between  them.  In  a 
moment  the  fixed  spasm  gives  way  to  clonic  convulsions.  The  face, 
body  and  extremities  twitch  violently,  and  the  head  beats  strongly 
backward.  During  this  stage  the  face  is  congested  and  often  bathed 
in  perspiration.  Foam  frequently  fills  the  mouth,  and  may  be  mixed 
with  blood  from  the  severely  bitten  tongue.  As  the  contractions 
cease,  the  child  sinks  down  exhausted,  limp  and  lifeless — except  for 
deep  sighing  respiration — into  a  state  of  profound  sleep  (postepilep- 
tic coma)  of  variable  duration.  With  return  of  consciousness  he  has 
no  knowledge  of  what  occurred.  The  duration  of  the  paroxysms 
varies  between  one  and  five  minutes.  It  may  occur  once  or  several 
times  a  day,  a  week  or  month,  or  may  not  return  for  several  months 
and  even  years.  A  certain  periodicity,  however,  is  demonstrable  in 
a  great  many  cases.  The  attacks  may  also  occur  at  night,  during  sound 
sleep. 

Petit  mal  is  usually  manifested  by  sudden  loss  of  consciousness  of 
very  short  duration.  The  patient  may  turn  pale,  stare  vacantly, 
twitch  a  little,  drop  what  he  is  holding,  and  then  recover  himself. 
Often  in  the  midst  of  play  the  child  suddenly  stands  fixed,  "as  if 
bewitched,"  with  staring,  absent-minded  facial  expression;  a  few  mo- 
ments later  he  resumes  his  play  as  though  nothing  had  happened,  or  sinks 
down  feebly_or  runs  toward  some  object  or  person  to  support  him- 
self. The  transition  (sometimes  after  years)  of  petit  mal  into  grand 
mal  is  not  rare,  and  should  always  be  remembered  in  fixing  the  dura- 
tion of  epilepsy. 

In  another  group  of  cases  the  convulsions  begin  in  one  particular 
muscle  or  group  of  muscles,  and  rapidly  spread  to  other  parts  of  the 
body.  Loss  of  consciousness  may  be  absent  or  occur  after  the  con- 
vulsions have  become  general.  It  is  often  followed  by  localized  pare- 
sis. This  cortical  or  Jacksonmn  form  of  epilepsy  is  based  upon  a  defin- 
ite local  lesion  in  the  cortex ;  it  is  acquired,  whereas  general  convulsions 
may  be  both  of  prenatal  or  postnatal  origin. 


DISEASES    OF    THE    NERVl:  'S?^TEJkf    i    ^^  '     "  ^.  "  (151 

Epilepsy  is  not  always  represented  by  so  typical  a  clinical  picture. 
Rudimentary  forms  are  encountered,  which  may  tax  the  skill  of  even 
the  best  observer  in  reaching  a  correct  conclusion. 

In  children  as  in  adults  instead  of  typical  or  atypical  attacks  of 
morbid  physical  phenomena,  momentary  states  of  mental  disturbances 
may  occur  which  may  vary  from  simple  confusion  up  to  acute  mania. 

These  fits  occasionally  alternate  wdth  convulsive  seizures.  Less 
common  than  in  adults  are  the  so-called  postepileptic,  frequently 
rather  proepileptic,  psychical  aberrations  which  are  manifested  by 
unconscious,  automatic,  more  or  less  violent  actions,  lasting  minutes, 
hours  or  days.  Inexplicable  disappearance  of  children  from  home  is 
not  rarely  an  epileptic  manifestation. 

Epilepsia  nutans  ("Salaamkrampf ")  is  manifested  by  sudden 
lightning-like  spasmodic  forward  movements*  (between  20  and  100) 
of  the  upper  part  of  the  body — a  sort  of  reverential  bow — and  is  as- 
sociated with  partial  or  complete  loss  of  consciousness. 

Epilepsia  procursiva  is  characterized  by  a  sudden  forced  start  of 
running,  of  variable  duration,  which  may  cease  abruptly  or  end  in  an 
attack  of  convulsions.  Consciousness  is  partially  lost  during  this 
seizure. 

Epilepsy  sooner  or  later  leads  to  permanent  mental  impairment. 
In  the  earlier  stages  this  may  consist  only  of  weakness  of  memory, 
silliness,  alteration  in  the  behavior  (the  child  may  be  cranky,  quarrel- 
some, destrucive,  etc.),  but  as  the  disease  becomes  chronic  the  pa- 
tient's mental  dulness  increases  and  may  reach  a  state  of  total  idiocy 
(see  p.  751).  Furthermore,  with  the  growing  mental  hebetude  there 
is  also  a  corresponding  development  of  coarse  features  with  a  down- 
cast, dazed,  and  stolid  facial  expression — physical  peculiarities  which  to 
the  keen  observer  often  betray  some  hidden  central  lesion.  This  obser- 
vation often  serves  well  in  the  differential  diagnosis  between  epilepsy 
and  reflex  and  hysteroid  convulsive  paroxysms.  (See  Spasmophilia 
and  Hysteria.) 

Treatment. — The  termination  of  epilepsy  is  subject  to  great  varia- 
tions. With  the  recent  gradual  improvement  in  the  methods  of  diag- 
nosis and  treatment,  complete  recovery  from  genuine  epilepsy  is  far 
from  being  exceptional.  This  refers  particularly  to  cases  due  to  reflex 
causes  (defective  vision,  adenoids,  worms,  phimosis,  etc.),  when  de- 
tected early  and  remedied.  To  a  great  extent  this  is  true  also  of  cases  re- 
sulting from  traumatism  or  benign  neoplasms,  which  are  nowadays  op- 
erated upon  more  or  less  successfully.  The  surgical  results  are  especially 
gratifying  in  the  Jacksonian  form  of  epilepsy.     Operative  interfer- 

*Similar  forward  movements  are   freriuently  observed  in   divers   forms  of  idiocy. 


3  Hi  T  6520  2  T  c  0    n  0  3  0  3  J  jIiSKXses  of  children 

e'nce,^  liowever,  should^  always  be  preceded  by  an  antisyphilitic  course 
of  treatment,  which  not  rarely  acts  admirably.  Some  cases  of  epil- 
epsy after  resisting  all  sorts  of  "cures"  for  a  number  of  years  get 
well  as  unexpectedly  as  they  got  sick.  Others  again  persist  for  life, 
do  what  you  may.  This  is  the  so-called  idiopathic  epilepsy,  for  which 
from  time  immemorial  the  whole  pharmacopeia,  witchcraft,  mental 
healing,  Christian  or  unchristian  Science,  etc.,  have  been  used  in  vain. 
What  can  be  accomplished,  however,  in  such  cases  is  the  lessening  of 
the  severity  and  frequency  of  the  attacks.  All  sources  of  irritation, 
however  trifling,  should  be  removed.  The  patient  should  be  placed 
on  a  light,  salt-free  diet  (milk,  bread,  cereals,  vegetables,  custards; 
eggs,  fish;  occasionally  well-boiled  meat;  plenty  of  fruit  and  water) 
under  the  best  possible  hygienic  conditions,  and  in  the  most  congenial 
and  restful  surroundings.  Residence  in  the  country,  with  plenty  of 
outdoor  air,  moderate  exercise  and  hydrotherapy  are  ideal  adjuvants. 

If  preceded  by  an  aura  sometimes  in  advance  of  the  fit,  the  latter 
may  occasionally  be  aborted  by  inhalation  of  amyl  nitrite. 

Immediate  attention  should  be  paid  also  to  the  convulsive  fit,  not 
alone  to  prevent  a  fatal  issue  from  cerebral  hemorrhage,  or  possibly 
from  apnea,  but  principally  to  avoid  grave  bodily  injury  which  the 
patient  is  apt  to  sustain  during  a  severe  fit.  When  the  attacks  are 
of  frequent  occurrence  the  child  should  not  be  left  alone,  especially 
in  a  room  with  an  open  fire,  or  in  the  vicinity  of  ponds,  rivers,  rail- 
road tracks,  etc.,  lest  he  be  suffocated,  fall  out  of  bed,  set  himself  on 
fire,  drown,  etc.  A  handkerchief  or  cork  should  be  placed  between 
the  child's  molar  teeth  to  prevent  biting  of  the  tongue.  A  severe  con- 
vulsive seizure  may  be  aborted  or  modified  by  a  few  whiffs  of  chloro- 
form, or  amyl  nitrite. 

Of  all  remedies  thus  far  recommended  the  bromides  are  the  only 
ones  which  have  proved  of  actual  benefit  in  all  forms  of  epilepsy. 
We  should  begin  with  moderate  doses  that  will  control  the  paroxysms. 
The  bromides  may  advantageously  be  combined  with  small  doses  of 
Prowler's  solution  of  arsenic.  The  treatment  should  be  continued, 
with  brief  intermissions,  to  avoid  bromism,  for  years — long  after 
cessation  of  the  attacks. 

IJ     Natrii  Bromidi 
Ammonii  Bromidi 
Strontii  Bromidi 
Liquor  Potassii  Arsenitis 
Mist.  Rhei  et  Sodae 
Syr.  Aurantii 
M. 

S. — One    teaspoonful    in    water    every   six    hours, 
and  later  only  twice  a  day,  for  a  child  six  years  old. 


aa  3  ii 

8.00 

Si 

4.00 

3  ss 

2.00 

3  ss 

1.5.00 

s.  ad  f  5  iii 

90.00 

DISEASES   OF    THE    NERVE    SYSTEM  653 

In  severe  fits  we  may  add  small  doses  of  codeine. 

When  the  bromides  are  not  well  tolerated  by  the  stomach  they 
may  temporarily  be  administered  per  rectum.  Postepileptic  out- 
breaks frequently  yield  to  early  administration  of  hypnotics,  espe- 
cially chloral.  Of  late  considerable  success  has  been  claimed  from  the 
administration  of  luminal  (phenylethylbarbituric  acid)  in  1  gr.  to  2 
gr.  doses,  once  or  twice  a  day.  It  is  supposed  to  be  a  non-habit-forming 
hypnotic  and  free  from  other  deleterious  effects.  It  is  prescribed  instead 
of  or  alternating  wnth  the  bromides. 

Migraine,  Hemicrania 

(Sick  Headache) 

There  is  reason  to  believe  that  the  seat  of  the  irritation  upon  which 
depend  the  pain  and  other  manifestations  of  hemicrania  lies  in  the 
brain  (in  the  cortex  or  deeper  cerebral  structures).  Cerebral  hyper- 
emia or  anemia  seems  to  be  the  immediate  cause  of  an  attack.  The 
remote  causes  are  very  numerous.  Gastrointestinal  autointoxication 
seems  to  play  a  prominent  role,  and  eyestrain,  nasopharyngeal  ab- 
normalities, dental  caries,  helminthiasis,  infectious  diseases,  and 
general  debility  are  often  found  to  act  as  predisposing  causes.  The 
disease  prevails  chiefly  among  nervous  children  over  eight  years  of 
age,  in  girls  more  frequently  than  in  boys.  To  some  extent  it  seems 
to  be  hereditary. 

Similar  to  epilepsy,  migraine  shows  a  distinct  periodicity  and  is 
frequently  preceded  by  premonitory  signs,  consisting  of  depression, 
irritability,  visual  disturbance,  tremor,  nausea  and  vomiting.  The 
child  complains  of  violent  headache,  usually  along  half  of  the  head 
(hemicrania)  or  occiput.  The  pain  is  increased  by  jars,  light,  and 
noises,  may  last  several  minutes,  hours,  or  days,  and  frequently  ter- 
minates with  an  attack  of  vomiting  followed  by  sound  sleep,  from 
which  the  patient  awakes  very  much  refreshed  and  apparently  per- 
fectly well.  A  prolonged  attack  is  not  rarely  accompanied  by  psychic 
disturbance  and  even  slight  convulsions,  in  which  event  it  may  re- 
semble organic  brain  disease,  e.  g.,  tuberculosis  of  the  brain.  The 
paroxysms  may  return  after  weeks,  days,  or  months,  at  all  events  the 
disease  runs  a  very  chronic  course,  especially  if  no  energetic  efforts  are 
made  to  determine  the  underlying  cause  and  to  remove  it. 

Treatment. — Where  the  cause  cannot  be  detected  or  removed,  a 
great  deal  of  benefit  is  usually  derived  from  improvement  of  the  gen- 
eral healtli,  especially  attention  to  existing  anemia,  constipation,  etc., 
and  regulation  of  diet.     Dilute  hydrochloric  acid  (5  drops,  well  di- 


654  DISEASES   OF   CHILDREN 

luted,  after  each  meal)  often  acts  very  beneficially.     Sojourn  in  the 
country. 

During  an  attack  the  patient  should  he  kept  quiet  in  bed,  in  a  dark, 
well-ventilated  room.  Local  moist  heat,  and  caffeine  and  quinine  (in 
cerebral  anemia),  and  phenacetin  and  ergot  with  sodium  bromide  (in 
cerebral  hyperemia)  are  of  service  to  relieve  the  intense  pain, 

IJ     Natrii  Bromidi  3i  4.00 

Antipyrina) 

Caffeinae  Natrii  Benzoatis  aa  3  ss  2.00 

Syr.  Aurantii  q.  s.  ad  f  5  ii  60.00 

M. 

S. — One  tcaspoonful  every  six  hours,  for  a  eliild 
six  years  old. 

Pavor  Nocturnus 

(Night  Terrors) 

Night  terrors  are  observed  chiefly  in  nervous  children  of  from 
three  to  eight  years  old.  Probably  frightened  by  a  horrible  dream 
(seeing  ferocious  animals,  etc.),  the  child  suddenly  awakes,  jumps  up, 
sits  up  in  bed  or  jumps  out,  looks  around  staringly  and  anxiously, 
cries  or  screams  for  help,  or  utters  incoherent  words.  After  a  few 
minutes  he  recognizes  those  about  him,  quiets  down  and  falls  asleep. 
The  attack  may  recur  once  or  more  times  a  night  or  at  longer  inter- 
vals, and  ultimately  disappears  (sometimes  not  until  puberty)  without 
serious  consequences.  In  rare  instances  pavor  nocturnus  forms  a 
precursor  of  epilepsy.  I  am  inclined  to  think  that  the  immediate 
cause  of  the  attack  is  a  cerebral  hyperemia. 

As  a  rule,  the  attack  is  aggravated  by  overloading  of  the  stomach  be- 
fore retiring,  faulty  feeding,  hearing  of  fearful  stories,  or  seeing  exciting 
shows,  the  presence  of  intestinal  worms,  adenoids  and  hypertrophied  ton- 
sils, and  other  local  disturbances,  and  usually  ceases  upon  removal  of  the 
aforementioned  causes.  The  patient  should  sleep  in  an  airy,  slightly 
illuminated  room,  on  a  hard  mattress,  lightly  covered  and  free  from 
tightly  fitting  night  clothes.  The  general  health  should  be  improved 
by  outdoor  air,  cod  liver  oil,  and  other  tonics.  A  moderate  dose  of 
sodium  bromide  at  bedtime  is  useful  to  check  frequently  recurring  at- 
tacks. 

Syringomyelia* 

Cavities  in  the  cord  may  occur  primarily  as  a  congenital  arrest  of 
development  or  secondarily  as  a  result  of  a   gliomatous  process  in 


"For  "Congenital  Malformations  of  the  Spinal  Cord,"  see  p.  197. 


DISEASES   OF    THE    XERVE    SYSTEM  055 

the  gray  (cervical  enlargement)  and  white  matter.  In  pronounced 
noncongenital  eases  it  is  manifested  by  gradual  loss  of  power  in  the 
upper  limbs,  trophic  disturbances  in  the  skin,  sul)cutaneous  tissue, 
and  bones  (glossy  skin,  ulceration  and  necrosis  of  the  phalanges), 
disturbance  of  sensibility  (partial  or  complete  loss  of  pain-  and  tem- 
perature-sense while  the  muscular  and  tactile  senses  are  preserved). 
Later,  signs  of  muscular  atroph}-— beginning  with  a  small  muscle  of 
the  hand  and  gradually  extending  up  to  the  shoulder — and  paralysis, 
first  of  the  upper  then  of  the  low^er  extremities,  set  in.  The  course  of 
the  disease  is  slow  and  occasionally  interrupted  by  stationary  periods. 

Spinal  Hemorrhage 

(Apoplexia  Spinalis,  Hem  atom  yelia) 

The  hemorrhage  may  be  outside  the  dura,  in  the  membranes,  or 
in  the  substance  of  the  cord.  It  is  usually  of  traumatic  origin — in- 
strumental delivery,  a  fall  or  blow,  or  severe  convulsions.  The  his- 
tory of  the  case,  therefore,  is  valuable  in  the  diagnosis.  Slight  hemor- 
rhage may  give  rise  to  no  definite  symptoms.  The  diagnosis  of  severe 
hemorrhage  is  based  upon  the  sudden  appearance  of  intense  pain  in 
the  back,  rigidity  of  the  spine,  sometimes  convulsions,  blood  in  the  cere- 
brospinal fluid,  and,  if  the  pressure  upon  the  cord  is  marked,  para- 
lytic symptoms.  (See  "Myelitis,"  p.  656.)  The  latter  are  especially 
pronounced  in  hemorrhage  into  the  gray  substance  of  the  cord.  Where 
the  hemorrhage  is  moderate  and  the  patient  survives  the  immediate 
attack,  the  tendency  of  the  affection  is  tow'ard  recovery.  This  may 
be  enhanced  b}^  absolute  rest  on  the  face  or  side  in  a  somewhat  prone 
position.  Local  abstraction  of  blood ;  ice  to  the  seat  of  injury.  Later 
attention  to  the  palsy.  Cases  due  to  fractures  and  direct  violence 
must  be  treated  surgically. 

Spinal  Meningitis 

In  the  majority  of  cases  inflammation  of  the  meninges  of  the  spinal 
cord  is  associated  with  that  of  the  brain.  (See  "Cerebrospinal  Men- 
ingitis".) Occasionally,  however,  the  inflammation  is  limited  to  the 
spinal  membranes,  similar  to  spinal  hemorrhage,  being  produced  by 
traumatism. 

The  symptoms  of  spinal  meningitis  are  practically  the  same  as 
in  spinal  hemorrhage,  except  that  the  former  affection  is  marked  by 
a  sharp  rise  in  temperature  at  the  onset,  and  by  a  more  progressive 
character  pf  the  symptoms.  Absolute  recovery  is  exceptional.  The 
treatment  is  symptomatic. 


656  DISEASES   OF    CHILDREN 

Myelitis 

This  affection  is  occasionally  observed  in  children  principally  as  a 
result  of  traumatism,  syphilis  and  compression  of  the  cord  by  tuber- 
culous masses  and  exudates  between  the  dura  and  vertebrae  second- 
arily to  spondylitis.  The  pathologic  process  in  the  cord  varies  with 
the  etiologic  factors.  Ordinarily  the  diseased  portion  is  at  first  red 
and  soft,  and  later,  yellow,  fatty  degenerated,  atrophied  and  scle- 
rosed. The  lesion  may  be  situated  in  any  part  of  the  cord  and  accord- 
ingly the  symptoms  differ  with  the  localization.  Thus,  in  disease  of 
the  cervical  region  there  is  first  involvement  (motor  paralysis  and  sen- 
sory disturbances)  of  the  upper  extremities,  then  of  the  lower,  and,  if 
the  lesion  is  very  high  up,  the  diaphragm  also  is  affected  and  respira- 
tion is  interfered  with.  In  disease  of  the  dorsal  portion  there  is  para- 
plegia (with  muscular  rigidity),  with  exaggeration  of  the  reflexes,  anes- 
thesia of  the  extremities,  paralysis  of  the  bladder  and  rectum  and 
decubitus.  In  myelitis  of  the  lumhosacral  region  the  paralysis,  etc.,  is 
the  same  as  in  the  former  lesion,  but  the  muscles  are  flaccid,  show  de- 
generative changes  to  electric  tests,  and  waste,  and  the  skin  and  tendon 
reflexes  are  abolished.  The  feet  fall  into  an  extended  position,  so  that 
the  instep  is  on  a  line  with  the  tibia.  In  partial  myelitis  the  symptoms 
are  less  pronounced,  extending  only  to  such  structures  as  are  innervated 
by  the  diseased  segment  of  the  cord.  In  unilateral  lesions  the  symptoms, 
of  course,  are  limited  to  the  affected  side. 

The  onset  may  be  sudden  or  slow,  according  to  cause.  Acute  cases 
set  in  with  chills,  moderate  fever,  nausea,  sometimes  vomiting  and  con- 
vulsions, radiating  pain  in  the  back  and  legs,  rapidly  followed  by  the 
aforementioned  signs.  Cases  with  gradual  onset,  e.  g.,  secondarily  to 
spondylitis  or  compression  by  extraspinal  growths,  are  manifested  by 
gradually  progressing  debility  of  the  muscles  supplied  by  the  spinal 
nerves  below  the  compressed  area  (see  p.  168),  neuralgic  pain,  and  dis- 
turbance of  the  bladder. 

If  the  primary  affection  (e.  g.,  tuberculosis,  syphilis)  can  be  reached 
and  remedied  before  destruction  of  the  cord  has  advanced  too  far,  the 
progress  of  the  disease  can  readily  be  arrested.  Otherwise  the  symptoms 
continue  to  grow  worse  and  at  best  can  only  be  improved  by  massage, 
passive  motion  and  faradization,  procedures  which  are  generally  em- 
ployed in  all  forms  of  chronic  paralysis.  Attention  should  be  paid  to 
the  bladder  (catheterization)  and  bowels,  and  particularly  to  the  skin, 
as  the  tendency  to  the  development  of  bed  sores  is  very  great. 


DISEASES    OF    THE    NERVE    SYSTEM  657 

Ataxia  Hereditaria  (Friedreich),  Heredo- 
ataxie  Cerebelleuse  (Marie) 

This  family  affection  which  is  traceable  through  several  generations, 
is  of  obscure  origin.  Syphilis  in  the  parents  is  most  probably  the 
cause.  The  anatomic  lesion — degeneration — is  situated  principally 
in  the  cord  (the  column  of  Goll,  and  partly  also  of  Burdach  and 
Clarke)  and  in  some  cases  also  in  the  cerebellum.  The  cord  as  a  whole 
is  very  thin  and  small,  i.  e.,  arrested  in  development. 

The  disease  attacks  the  patient  insidiously,  between  the  sixth  and 
fifteenth  years  of  life,  with  symptoms  of  simple  progressive  incoordina- 
tion of  the  lower  limbs,  trunk  and  arms — irregular  swaying  resembling 
that  of  chorea.  Later  also  nodding  of  the  head.  Gradually  the  tabetic 
cerebellar  gait  develops,  so  that  the  child  is  ultimately  unable  to  walk 
or  stand.  As  the  disease  progresses,  speech  becomes  peculiar,  slightly 
scanning,  heavy  and  awkward,  vision  disturbed  by  nystagmus,  and  ex- 
ceptionally by  optic  atrophy  (Argyll-Robertson  symptom  is  absent,  while 
Romberg's  is  occasionally  present),  the  fac3  expressionless,  the  general 
musculature  paralyzed,  atrophied,  the  spinal  column  curved,  the  feet 
humpy  looking  with  the  toes  turned  up  {Friedreich's  foot),  and,  finally 
intelligence  impaired.  Unprovoked  and  uncontrollable  laughter  is  said 
to  be  characteristic  of  the  disease.  As  a  rule,  sensation  and  the  cutane- 
ous reflexes  remain  undisturbed;  the  sphincters  are  intact  until  very 
late,  while  the  tendon  reflexes  are  abolished.  The  course  of  the  disease 
is  very  chronic.  The  patient  is  usually  bedridden  after  a  period  of 
from  five  to  ten  years,  but  he  may  continue  to  live  in  this  state  for  an- 
other ten  years. 

Disseminated  Sclerosis 

(Multiple  Sclerosis) 

The  etiology  of  diffuse  and  disseminated  sclerosis  is  not  definitely 
known.  It  is  either  congenital,  and  traceable  to  alcoholism  or  syphilis 
in  the  parents,  or  is  met  with  in  young,  apparently  healthy  and  normally 
developed  children  some  time  after  traumatism  or  an  attack  of  an  in- 
fectious disease. 

Its  onset  is  usually  insidious  with  disturbances  of  motion,  loss  of 
memory,  and  dulness  of  intellect,  soon  to  be  followed  by  defective 
speech  (at  first  slow  and  later  scanning),  hearing,  and  vision  (nys- 
tagmus, amaurosis,  and  strabismus),  spastic  paraplegia  (weakness  and 
rigidity  first  of  the  upper  extremities,  then  of  the  lower;  exaggerated 
tendon  reaction  and  ankle  clonus)  and  intention  tremor.  In  the  later 
stages   of   the   disease   the   patient  loses   control   of   the   bowels  and 


658  DISEASES   OF   CHILDREN 

bladder,  suffers  from  difficult  deglutition,  attacks  of  vertigo,  loss  of 
consciousness  and  convulsions,  and  finally  enters  into  a  state  of  mental 
and  physical  exhaustion,  paralysis  and  idiocy.  Death  occurs  after 
several  years. 

The  symptoms  just  enumerated  do  not  all  prevail  in  every  case. 
They  differ  with  the  location  of  the  sclerosed  patches.  As  a  rule,  the 
latter  are  found  not  only  in  the  brain  but  in  the  medulla  and  spinal 
cord  as  well — chiefly  in  the  white  substance. 

Treatment. — The  disease  is  very  rarely  influenced  by  treatment. 
Antisyphilitic  medication,  however,  is  worth  trying. 

HEREDITARY  PROGRESSIVE  MUSCULAR  ATROPHIES 

(I.  SPINAL;  II.  NEUEAL;  III.  MYOGENIC) 

This  classification  is  intended  solely  to  emphasize  the  principal 
locations  of  the  underlying  lesions.  This  disease  is  transmitted  from 
generation  to  generation  and  often  affects  several  members  of  the 
same  family. 

I.  Spinal  Progressive  Muscular  Atrophy- 
It  is  observed  in  early  infancy.  It  begins  with  weakness  of  the 
muscles  of  the  legs,  neck,  back,  throat,  shoulders,  arms,  hands,  fingers 
and  toes.  As  the  disease  advances  the  muscles  are  completely  atro- 
phied (rarely  pseudohypertrophied)  so  that  the  child  is  entirely  help- 
less. The  reflexes  are  abolished  and  the  electric  reaction  greatly  dis- 
turbed. The  disease  ends  fatally  within  about  four  years  from  in- 
volvement of  the  respiratory  muscles  and  consecutive  pneumonia. 
The  lesion  consists  of  atrophy  of  the  cells  of  the  anterior  cornu  of  the 
entire  spinal  cord  and  degeneration  of  the  motor  nerve  fibers.  There 
is  no  central  involvement,  hence,  cerebral  symptoms  are  absent.  The 
sphincters  are  intact.    Fibrillar  twitching  is  infrequent. 

II.  Neural  Progressive  Muscular  Atrophy 

(Peroneal  Type) 

It  is  characterized  by  atrophy  beginning  with  the  muscles  of  the  legs, 
especially  the  peroneal  group,  and  by  predominence  of  sensory  dis- 
turbances, hyperesthesia  or  anesthesia.  In  walking  the  child  lifts  the 
feet  high  and  touches  the  floor  with  the  tips.  If  the  muscles  of  the 
hands  are  affected,  the  hands  become  claw-shaped.  Occasionally  other 
muscles  are  implicated.  The  patellar  and  Achilles'  tendon  reflexes 
are  at  first  diminished  and  later  abolished.     The  electric  reaction  of 


DISEASES   OF    THE    NERVE    SYSTEM  659 

the  atrophied  muscles  varies — is  normal  in  some  cases,  disturbed  in 
others — irrespective  of  the  nature  of  the  atrophy.  Fibrillar  tvvitchings 
are  common.  The  course  of  the  disease  is  very  slow  and  interrupted  by 
remissions  of  variable  length,  and  judging  by  the  underlying  pathologic 
anatomy  of  the  affection  (degeneration  of  the  respective  peripheral 
nerves,  with  slight  implication  of  the  spinal  cord)  it  is  per  se  probably 
not  fatal.    Massage,  baths  and  electricity  are  of  benefit. 

III.  Myogenic  Progressive  Muscular  Atrophy 

(Dystrophia  Muscularis,  Pseudohypertrophic  Paralysis) 

Under  this  heading  are  grouped  the  following  four  morbid  condi- 
tions which  were  formerly  looked  upon  as  distinct  pathologic  en- 
tities: 

(a)  Simple  Hereditary  Muscular  Atrophy.  It  usually  attacks 
children  between  eight  and  ten  years  of  age,  and  is  manifested  by 
weakness  and  atrophy  of  the  muscles  of  the  back  (without  pseudo- 
hypertrophy), lordosis  and  paresis. 

(b)  Infantile  Muscular  Atrophy  (Facioscapulohumeral  Type,  Lan- 
douzy-Dejerine). — As  the  name  indicates  it  begins  in  early  infancy 
Avith  atrophy  of  the  face,  especially  the  orbicularis  oculorum  and  oris 
and  the  lips.  The  patient  is  unable  to  close  the  eyes,  to  point  the 
mouth,  and  his  face  becomes  expressionless,  like  a  mask.  Pseudo- 
hypertrophy of  the  facial  muscles  sets  in  later,  so  also  the  atrophy 
of  the  muscles  of  the  scapulohumeral  regions. 

(c)  Juvenile  Muscular  Atrophy  (Erb). — The  atrophy  is  manifested, 
at  a  later  age  than  in  the  former  variety,  in  the  following  order:  The 
pectorales,  the  anterior  serrati,  the  latissimus  dorsi,  the  rhomboidei, 
and  the  trapezius  muscles,  and  then  the  triceps,  biceps,  brachioradial 
and  brachial  muscles.     The  deltoid  is  usually  strongly  hypertrophied. 

(d)  Pseudohypertrophy  (Duchenne). — In  this  form  of  the  disease 
the  muscles  first  affected  are  those  of  the  calves,  the  extensors  of  the 
thighs  Avhich  become  greatly  enlarged,  and  then  the  long  spinal  mus- 
cles. As  the  disease  progresses  the  shoulder,  arm  and  lumbar  muscles 
become  involved,  the "  deltoid,  supra-  and  infraspinati  showing  an 
especial  tendency  to  pseudohypertrophy.  The  forearm  and  hands 
remain  free.  Owing  to  the  w^eakness  of  the  erector  spinge  and  glutei 
muscles,  the  patient  keeps  his  trunk  thrown  backward,  ''saddle- 
back," and  walks  with  a  peculiar  waddling  gait,  with  the  legs  widely 
separated  and  the  toes  barely  touching  the  ground.  The  gait  at  times 
resembles  that  of  bilateral  dislocation  of  the  hip.  If  placed  on  the 
floor,  the  efforts  made  to  rise  are  very  characteristic.     Awkwardly 


660 


DISEASES   OF    CHILDREN 


and  with  difficulty  he  places  first  one  hand  and  then  the  other  on  the 
legs,  then  on  the  thighs  above  the  knees;  and  in  this  manner  he 
'^ climbs  upon  himself"  until  he  assumes  the  erect  position  (see  Figs. 
191,  192,  193).    In  time,  the  patient  becomes  unable  even  to  sit  up. 

The  distinction  between  the  different  forms  of  myogenic  dystrophia 
cannot  always  be  made  with  exactness,  as  the  order  with  which 
atrophy  begins  is  not  rarely  reversed.  All  varieties  of  the  affection 
at  a  late  stage  present  diminution  of  the  tendon  and  electric  reactions, 
but  no  reaction  of  degeneration  or  central  disturbance.     Fibrillary 


Fig.  191.  Fig.  192. 

Figs.    191-193. — Pseudohypertrophic    paralysis.      Demonstration    of    mode    of    rising 
from  the  floor  by  ' '  climbing  upon  liimself . ' ' 

twitching  of  the  atrophied  muscles  is  absent  and  local  vasomotor  dis- 
turbances are  rare.  As  the  disease  advances  and  the  paralyzed  mus- 
cles contract,  various  deformities  (spinal  curvature,  talipes,  etc.)  make 
their  gradual  appearance  and  render  the  patient  totally  helpless  and 
bedridden. 

The  course  of  the  disease  is  slow,  and  occasionally  interrupted  by 
remissions  of  variable  length,  and  temporary  improvement.  Death 
usually  takes  place  within  ten  years  from  the  onset  of  the  affection, 
as  a  rule,  from  intercurrent  diseases,  especially  pneumonia. 

Treatment. — The  treatment  in  the  form  of  baths,  massage,  etc.,  may 


DISEASES   OF    THE   NERVE    SYSTEM 


661 


prove  effective  to  check  the  progress  of  the  manifestations,  but  it  is 
doubtful  if  it  ever  leads  to  permanent  recovery. 

The  disease  is  attributed  to  an  extraordinary  increase  of  connec- 
tive   and    adipose    tissues   with    corresponding   atrophy    and    gradual 


Fig.  193. 

disappearance  of  fibers  of  certain  muscles.  Slight  lesions  are  not 
rarely  found  also  in  the  cord.  The  etiology  is  obscure.  The  absence 
of  fibrillar  twitching  and  of  atrophy  of  the  hands  and  forearms  serves 
as  differential  points  from  "Spinal  Progressive  Muscular  Atrophy." 
(See  p.  658.) 

Lipodystrophia  Progressiva 

Lipodystrophia  progressiva  is  a  term  applied  by  Simons*  to  a  syn- 
drome beginning  most  frequently  between  the  fifth  and  twelfth  years, 
and  chiefly  aff'ecting  females.     In  this  condition,  there  occurs  a  grad- 


*A.   Simons   (Zeitschr.  f.  d.  Ges.  Neur.  w.   Psych.,  Berlin,   1911). 


662  DISEASES   OF    CHILDREN 

iial,  progressive  emaciation,  beginning  in  the  face,  and  progressing 
downward,  involving  the  neck,  shoulders,  trunk  and  upper  extremities 
and  in  most  of  the  cases  reported,  an  increased  deposit  of  fat  in  the 
buttocks,  thighs  and  sometimes  the  legs.  The  gradual  disappearance 
of  fat  progresses  until  the  appearance  of  the  face  is  most  character- 
istic. The  cheeks  become  sunken,  the  eyes  deeply  set,  the  malar  emi- 
nences prominent,  and  the  temporal  regions  sunken.  When  the  pa- 
tient smiles,  the  cheek  is  thrown  into  deep  folds  and  the  face  generally 
has  a  cadaverous  appearance.  The  neck  becomes  thin,  the  clavicles 
and  scapulsB  extend  prominently  forward.  The  intercostal  spaces 
are  well  marked;  the  breasts  are  pendulous  and,  owing  to  the  disap- 
pearance of  the  fat,  hard  and  nodular. 

In  contrast  to  the  wasted  appearance  of  the  upper  extremities  and 
face,  the  parts  below  the  line  of  the  iliac  crests  of  the  individual  present 
a  plump  appearance ;  in  some  of  the  cases  reported  even  amounting  to 
grotesqueness. 

Usually,  the  attention  of  the  family  is  first  called  to  this  condition 
by  the  emaciation  which  takes  place  in  the  face,  and  the  fear  of 
some  acute  disease  prompts  them  to  seek  medical  advice.  The  pa- 
tients themselves  complain  little  or  not  at  all.  In  advanced  cases 
they  sometimes  complain  of  feeling  chilly  and  of  excessive  perspi- 
ration or  in  other  cases,  of  weakness  or  nervousness. 

In  all  cases  there  is  a  gradual  progression  of  the  emaciation  of  the 
face,  upper  extremities  and  trunk,  and  increase  in  size  of  the  lower 
extremities  over  a  period  of  ten  to  twenty  years,  after  which  there  is 
spontaneous  arrest. 

According  to  I.  J.  Spear  (Archives,  Int.  Med.,  January,  1918)  this 
condition  is  rather  uncommon,  only  24  cases  having  thus  far  been 
reported. 

Treatment. — Therapy  seems  of  no  avail.  Paraffin  injections  have 
been  recommended  for  corrective  cosmetic  purposes. 

Tumors  of  the  Cord  and  Membranes 

Neoplasms  of  the  cord  are  very  rare  and,  hence,  principally  of 
pathologic  and  diagnostic  interest.  They  may  be  primary  (some 
times  congenital)  or  secondary.  Tubercle  is  the  most  frequent  variety 
observed;  next  in  frequency  are  gliomas,  syphilomas,  lipomas  and 
sarcomas. 

The  symptomatology  depends  upon  the  seat  of  the  growth,  essen- 
tially resembling  that  of  myelitis,  except  that  it  is  of  gradual  de- 
velopment. In  benign  unilateral  tumors  the  symptoms  (motor  and 
sensory  paralysis)  are  limited  to  the  side  affected. 


DISEASES    OF    THE    NERVE    SYSTEM 


663 


Treatment. — Antisyphilitic  treatment  deserves  a  full  trial,  and,  if 
this  fails,  operative  interference  should  be  resorted  to. 

Peripheral  Facial  Paralysis 

(Bell's  Palsy) 

Facial  paralysis  may  be  due  to  trauma,  pressure  and  irritation  (swell- 
ing or  disease)  from  contiguous  structures  (glands,  teeth,  ears)  or  ex- 
posure to  cold  or  draughts. 

The  symptomatology  is  essentially  alike  in  all  cases  irrespective  of 
cause.  The  paralysis  is  usually  unilateral  and  effects  the  muscles  of  the 
forehead,'  the  orbicularis  oculi  and  some  of  the  lower  facial  muscles. 
As  a  result,  the  paralyzed  side  of  the  face  is  lax  and  expressionless,  the 


Fig.  194. — Peripheral  facial  palsy — Bell's  palsy.  Note  inability  to  close  right 
eye  and  to  frown,  as  with  the  muscles  of  the  left  side  of  the  forehead.  Lower  part 
of  face  unaffected. 

nasolabial  fold  more  or  less  effaced;  the  eye  remains  widely  open  and 
the  angle  of  the  mouth  droops.  The  paralysis  becomes  especially  pro- 
nounced, when  the  muscles  are  thrown  into  action,  e.  g.,  on  laughing  or 
crying.  In  severe  cases  there  is  also  paresis  of  the  soft  palate,  and  im- 
pairment of  speech  and  mastication,  and  occasionally  dulness  of  taste 
and  diminished  secretion  of  saliva.  In  otic  facial  palsy  there  may  be 
disturbance  of  hearing  (deafness;  hyperacuteness).  In  the  so-called 
rheumatic  variety  or  that  due  to  exposure,  the  onset  is  usually  sudden 
and  accompanied  by  neuralgic  pain.  The  electric  reaction  remains  nor- 
mal in  mild  cases,  but  is  diminished  or  lost  in  grave  cases. 


664 


DISEASES   OF    CHILDREN 


Prognosis  and  Treatment. — The  prognosis  and  treatment  depend  upon 
the  etiologic  factors.  Traumatic,  especially  obstetric  facial  palsy 
{q.  v.),  where  the  trauma  is  slight,  usually  ends  favorably  within  a 
few  weeks — without  any  therapeutic  measures. 

Facial  palsy  arising  from  involvement  of  the  facial  nerve  by  aural 
suppurative  processes  (middle  ear  disease;  caries  of  the  petrous  por- 
tion), usually  runs  a  more  protracted  course,  often  long  after  the  re- 
moval of  the  cause.  Early  attention  to  the  ear  affection  is  of  vital 
importance.  Cases  resulting  from  dental  caries  can  readily  be  remedied 
by  treatment,  possibly  extraction  of  the  diseased  tooth. 

Rheumatic,  grippal,  etc.,  facial  palsy  ordinarily  responds  to  local 
heat,  the  salicylates,  quinine  and  arsenic.  Pressure  neuritis  usually 
abates  with  disappearance  of  the  swelling  exerting  the  pressure  upon 


Fig.  195. — Nuclear  facial  palsy.     Eye  muscles  are  unaffected;   paralysis  limited  to 

lower  part  of  face. 

the  nerve.  Facial  palsy  occurring  in  connection  with  parotitis  calls  for 
no  special  treatment.  Where  the  pressure  is  due  to  a  new  growth, 
enucleation  of  the  latter  should  be  promptly  undertaken.  Recovery  is 
not  as  rapid  in  the  latter  form  as  in  the  other  varieties. 

After  abatement  of  the  hyperacute  symptoms,  a  weak  galvanic  cur- 
rent should  be  applied  four  to  six  times  a  week,  for  from  two  to  three 
minutes  at  a  time.  The  anode  should  be  held  behind  the  ear,  while  the 
different  facial  nerve  branches  and  muscles  are  stroked  with  the  cathode. 

It  has  been  observed  that  recovery  is  assured — after  a  shorter  or 
longer  period  of  time — in  all  cases  of  facial  paralysis  in  which  the 
electric  reaction  remains  normal  after  a  lapse  of  from  one  to  two  weeks. 
On  the  other  hand,  cases  which  present  complete  reaction  of  degenera- 
tion of  nerve  and  muscles  after  that  period  of  time  usually  offer  a  doubt- 


DISEASES    OF    THE    NERVE    SYSTEM  665 

fill  prognosis.  Protracted  cases  may  lead  to  degeneration  and  shortening 
of  the  affected  muscles,  so  that  tlie  face  appears  drawn  to  the  paralyzed 
side. 

Peripheral  facial  paralysis  should  not  be  mistaken  for  central  or 
nuclear  facial  palsy.  In  cerebral  palsy  the  muscles  of  the  forehead  and 
eyes,  for  the  most  part,  escape  (;'.  e.,  the  patient  is  able  to  frown  and  to 
close  the  eye  on  the  affected  side);  the  electric  reaction  is  retained; 
furtliermore,  the  palsy  is  frequently  associated  with  hemiplegia  of  the 
same  side.  In  nuclear  or  basilar  paralysis  the  palsy  is  usually  limited 
to  the  lower  half  of  the  face  (from  the  mouth  down)  and  is  complicated 
by  other  symptoms  indicating  a  lesion  in  the  pons,  such  as  cross 
paralysis  and  disturbed  action  of  other  cranial  nerves. 

Facial  paralysis  w^th  lost  electric  reaction  may  often  be  mistaken  for 
the  permanent  facial  paralysis  following  acute  poliomyelitis,  (q.  v.) 
Indeed,  there  is  reason  to  believe  that  the  so-called  idiopathic  form  of 
facial  paralysis  which  resists  all  methods  of  treatment  is  in  reality  of 
poliomyelitic  origin. 

Hemiatrophia  Faciei 

(Progressive  Facial  Hemiatrophy) 

The  nature  of  this  rare  affection  is  still  obscure.  The  pathologic 
findings  point  to  an  interstitial  inflammatory  process  of  the  trigem- 
inus. It  occurs  in  girls  more  frequently  than  in  boys,  on  the  left  side 
more  than  on  the  right,  and  exceptionally  affects  both  sides  of  the 
face. 

It  begins  with  a  small  part  of  the  face  (usually  over  the  fossa  ca- 
nina)  turning  white,  thin,  wrinkled,  etc.  From  here  the  atrophy 
rapidly  spreads  to  the  muscles  and  bones  of  the  entire  half  of  the 
face,  including  the  hair.  At  times  the  atrophy  spreads  to  the  chest 
and  other  parts  of  the  body,  but  finally  reaches  a  permanently  quies- 
cent stage.  Sometimes  there  are  also  anomalies  of  pigment.  It  is 
occasionally  associated  with  scleroderma  and  exophthalmic  goiter. 
Sensation  remains  intact  and  the  electric  reactions  are  normal. 

Treatment. — The  cause  of  the  atrophy  being  unknown,  the  treat- 
ment must,  necessarily,  be  symptomatic.  Parafftne  injections  have 
proved  very  useful  to  correct  the  remaining  facial  deformity. 

Polyneuritis 

(Multiple  Neuritis) 

Polyneuritis  is  an  inflammatory,  degenerative  affection  of  the  periph- 
eral nerves.     During  the  early  stage  only  the  sheaths  of  the  nerves 


G66  DISEASES   OF    CHILDREN 

are  affected  (hyperemic  and  the  seat  of  minute  hemorrhages).  As  the 
disease  progresses  we  find  connective  tissue  cells  between  the  nerve 
sheaths,  and  red  spindle-shaped  cells  between  the  nerve  fibers,  and  also 
parenchymatous  changes  in  the  muscles.  In  severe  cases  the  lesions 
ascend  to  the  nerve  trunks  or  even  to  the  roots.  Its  distribution  is  al- 
most always  bilateral  and  symmetrical.  Polyneuritis  is  very  rarely 
observed  in  children,  since- the  principal  causes  of  the  affection— alcohol- 
ism, lead,  and  arsenic  poisoning — are  of  exceptional  occurrence  in 
young  children.  The  most  frequent  form  of  polyneuritis  encountered  is 
that  described  as  ''Diphtheritic  Paresis"  (see  Diphtheria),  and  on 
very  rare  occasions  it  is  encountered  also  in  connection  with  other 
infectious  diseases.  In  one  case  under  our  observation  (see  Fig.  196) 
the  pain  and  paresis  set  in  six  weeks  after  an  attack  of  diphtheria. 


Fig.  196. — Diphtheritic  polyneuritis  in  Fig.  197. — Same  case  as  Fig.  196  two 

a  boy  four  years   old,  affecting   several       weeks  later.     Note  considerable  improve- 
groups  of  muscles  of  the  neck,  trunk  and       ment. 
extremities.      Note   his   inability    to   rise 
from  the  floor. 

The  paresis  was  very  extensive  and  affected  the  muscles  of  the  palate 
and  throat  (aphonia)  neck,  trunk,  lower  extremities  and  slightly  the 
arms.  The  four-year-old  boy  recovered  completely  within  about  two 
months.  Strychnine  was  the  only  remedy  used.  The  neck  was  sup- 
ported by  a  felt  collar. 

The  onset  of  multiple  neuritis  is  usually  fairly  rapid,  with  numbness, 
pricking,  pain  and  chilliness  of  the  parts  affected.  This  is  followed  by 
the  appearance  of  motor  incoordination  (ataxia,  waddling  gait)  up  to 
paralysis  of  symmetrical  groups  of  muscles  {e.  g.,  of  the  hands  and 
feet)    or  of  entire  extremities.     The  symptoms  usually  get  gradually 


DISEASES   OF    THE    NERVE   SYSTEM 


667 


worse  for  about  four  weeks.  The  lower  extremities  are  ordinarily  af- 
fected first  and  the  upper  later.  Genuine  foot-  and  wrist-drop  is  rare. 
The  same  is  true  of  involvement  of  the  muscles  of  the  trunk,  and  the 
sphincters.  Exceptionally  the  diaphragm  is  affected.  The  motor  symp- 
toms are  usually  associated  with  sensory  disturbances — pain,  especially 
on  pressure,  along  the  nerve  trunks,  hyperesthesia  and  more  rarely 
anesthesia.  The  electric  and  tendon  reactions  are  diminished,  and  re- 
action of  degeneration  is  quite  common  in  severe  cases. 


Fig.  198. — Same  case  as  Fig.  196  six  weeks  later.     He  is  practically  well,  except  for 
remaining  weakness  of  the  muscles  of  the  neck. 

Treatment. — With  early  treatment — elimination  of  the  poison 
(sodium  iodide,  magnesium  sulphate,  in  lead  poisoning),  mitigation 
of  pain  (salicylates,  warm  baths),  tonics  (strychnine,  iron,  etc.),  and 
galvanic  electricity  and  massage, — the  prognosis  is  usually  favorable, 
except  when  the  respiratory  muscles  are  affected.  In  such  cases  com- 
plicating bronchopneumonia  often  ends  fatally.  Occasionally  atrophy, 
with  consecutive  contractures  and  deformities,  may  persist  for  a  long 
time,  and  even  for  life. 


668 


DISEASES    OF    CHILDREN 


Differential  Diagnosis 


polyneuritis 

poliomyelitis                 LANDRY  'S    DISEASE 

Onset    

Usually  slow.     Slight 
fever,  if  any 

Quite  acute;  often         Slight  prodromata 
vomiting.       Moder-       (pain)  ;  no  fever 

ate  fever 

Distribution   of 

Symmetrical.          Par- 

Irregular.    Complete ; 

At  first  asymmetrical. 

paralysis    .... 

tial.      Lower,    then 

often  only  one 

Ascending.        Com- 

upper    extremities. 

limb,  or  a  group  of      plete.     Legs,  trunk, 

Exceptionally  other 

muscles,  e.g.,  shoul-,      arms,    and    muscles 

parts  of  body 

der  or   face. 

innervatcd  from  the 
medulla 

Hyperesthesia   .  . 

Persistent 

Transient 

Variable 

Anesthesia 

Present   (partial) 

Al)sent 

Absent 

Atrophy  and  de- 

Late and  slight 

Early 

Very  late,  if  at  all 

formities    .... 

Termination     . .  . 

As  a  rule,  gradual 

Partial,    spontaneous, 

Usually    fatal    within 

recovery 

recovery 

two  weeks.  Excep- 
tionallv,   recovery 

The  history  of  the  case  is  very  helpful  in  the  diagnosis.  Thus,  in 
multiple  neuritis,  we  are  often  able  to  elicit  a  history  of  some  form 
of  toxemia  (infectious  disease,  especially  diphtheria,  lead,  arsenic,  or 
alcohol  poisoning)  ;  in  poliomyelitis  its  prevalence  in  epidemic  form 
may  be  decisive. 

Polyneuritis  may  occasionally  be  mistaken  for  hereditary  ataxia — 
very  slow  in  development,  involvement  of  cranial  nerves,  and  mental 
debility;  and  myelitis — sphincters  invariably  involved. 


B.  FUNCTIONAL  DISEASES 

Spasmophilia 

(Eclampsia  Infantum,  Tetanism,  Tetany,  Pseudotetanus, 
Spasmus  Glottidis) 

The  subject  in  question  is  of  great  clinical  interest,  and  still  shrouded 
in  mystery.  Spasmodic  affections  are  generally  attributed  to  a  number 
of  local  bodily  irritations  which  act  reflexly  upon  the  central  nerve 
system.  We  know  also  that  the  infantile  brain  is  very  vascular,  very 
irritable,  very  impressionable,  lacking  in  power  of  resistance  and  con- 
trol. We  are  in  the  dark,  however,  as  to  why  the  very  same  etiologic 
factors  are  prone  to  produce  mild  or  severe  convulsions  in  one  child 
and  none  at  all  in  the  other.  This  apparent  discrepancy  in  action  leads 
one  to  assume  that  some  children  are  born  with  a  marked  (familial?) 
tendency  to  spasmodic  affections.  This,  probably  hereditary,  spasmodic 
tendency  ("spasmophilia")  is  distinctly  traceable  in  children  of  nerv- 
ous, alcoholic,  syphilitic  or  tuberculous  parentage,  and  exerts  its  influ- 
ence principally  on  the  group  of  functional  spasmodic  affections  pres- 
ently to  be  described. 


DISEASES    OF    THE    NERVE   SYSTEM  669 

I.  Eclampsia  Infantum 

(Convulsions) 

Nonepileptic  convulsions  are  of  common  occurrence  in  children,  es- 
pecially in  infants  under  one  year  of  age  and  are  the  immediate  result 
of  an  irritation  of  the  centers  in  the  pontobulbar  junction  or  in  the  area 
of  Rolando,  superinduced  either  by  cerebral  anemia  or  hyperemia. 
They  may  occur  as  a  partial,  often  initial  phenomenon  of  all  sorts  of 
acute  systemic  disturbances,  e.  g.,  toxemia  from  infectious  diseases; 
gastrointestinal  intoxication ;  shock,  and  trauma ;  or  in  consequence  of 
continued  reflex  irritations,  such  as  phimosis,  adenoids,  intestinal 
worms,  intense  pain  from  various  causes,  earache,  difficult  teething, 
calculi,  and  the  like.  In  quite  a  number  of  children,  a  rise  of  tempera- 
ture from  whatever  cause  will  produce  intense  convulsions  and  will 
continue  to  recur  until  the  temperature  has  been  reduced.  The  fre- 
quency of  the  convulsive  seizures  is  within  no  definite  limits — from  one 
attack  in  several  months  up  to  as  many  as  thirty  or  more  attacks  in  a 
day.  In  mild  cases  the  convulsions  may  be  manifested  merely  by  twitch- 
ing of  the  lips  or  eyelids,  etc. ;  in  severe  cases,  however,  the  convulsions 
are  both  tonic  and  clonic  in  character.  In  the  beginning,  the  body  is 
more  or  less  rigid,  the  head  and  neck  are  retracted,  the  eyeballs  are 
turned  upward  or  roll  spasmodically  in  different  directions.  The  face 
is  distorted  and  grows  cyanotic  as  breathing  becomes  labored  or  tem- 
porarily ceases.  These  tonic  spasms  are  soon  replaced  by  clonic  convul- 
sions— irregular  and  rapid  twitching  of  the  extremities  and  face  or  of 
single  groups  of  muscles — which  may  last  from  a  few  seconds  to  several 
minutes,  may  remit,  and  return  with  greater  violence.  With  complete 
cessation  of  the  convulsions  the  patient  usually  falls  asleep,  to  wake 
up  apparently  free  from  cerebral  disturbance.  During  the  attack  con- 
sciousness is  lost.  Occasionally,  there  may  be  loss  of  sensation  as  well 
as  involuntary  urination  and  defecation,  foaming  from  the  mouth  and 
biting  of  the  tongue — a  group  of  symptoms  which  is  generally  met  in 
epilepsy.  This,  together  with  the  fact  that  eclampsia  is  not  rarely  a 
precursor  of  genuine  epilepsy,  should  put  the  physician  on  his  guard 
in  venturing  a  positive  view  as  to  the  nature  and  curability  of  the 
spasmodic  affection. 

Epilepsy  differs  from  infantile  eclampsia  in  that  the  fit  is  preceded 
by  an  aura,  that  it  is  of  short  duration  but  nonremittent,  and  that  it 
is  invariably  followed  by  profound  sleep — not  the  light  sleep  which 
follows  eclampsia.  We  should  bear  in  mind,  however,  that  these  dif- 
ferential signs  are  much  less  reliable  in  epilepsy  of  children  than  in 
adults. 


670  DISEASES   OF   CHILDREN 

Eclampsia  infantum  is  to  be  carefully  distinguished  from  uremic 
convulsions,  and  spasms  accompanying  brain  disease.  In  uremia 
there  is  usually  a  history  (scarlatina?)  of  suppression  of  urine.  The 
latter  reveals  evidences  of  kidney  disease.  Cerehral  convulsions  are 
associated  with  projectile  vomiting,  possibly  a  history  of  trauma,  tuber- 
culosis, otic  abscess,  and  the  like.  The  convulsions  of  organic  brain 
disease  (tumor  or  abscess)  are  apt  to  be  more  localized  and  be  followed 
by  paralytic  phenomena. 

Treatment. — When  called  upon  to  treat  a  child  in  an  attack  of 
convulsions,  the  physician  is  rarely  in  position  to  make  exact  and 
scientific  discriminations  betAveen  the  different  forms  of  convulsions. 
It  is  essential  to  arrest  the  convulsions  irrespective  of  cause  or  effect, 
since  a  prolonged  attack  may  end  fatally  from  exhaustion  or  suffoca- 
tion. The  spasms  are  best  controlled  by  means  of  chloroform  inhaled 
from  a  loosely  applied  handkerchief,  moistened  with  %  to  1  teaspoon- 
ful  of  the  anesthetic.  In  this  manner  the  anesthetic  may  be  contin- 
ued, at  long  intervals,  for  hours  or  days  without  endangering  the  life 
of  the  patient.  As  the  convulsions  subside,  we  begin  to  make  careful 
inquiry  into  their  causation  and  to  employ  the  therapeutic  measures 
indicated  in  each  individual  case.  Hyperpyrexia  calls  for  hydro- 
therapy (cold  sponge  or  tub  bath);  gastroenteric  disorders,  for  emesis 
(apomorphine  1/16  grain  hypodermatically,  or  ipecac  by  mouth), 
catharsis  (2  grains  of  calomel  in  one  dose),  and  enteroclysis;  intestinal 
worms,  for  teniafuges  (turpentine  inhalation,  and  calomel  and  san- 
tonine  by  mouth) ;  nervous  disturbances,  for  hot  baths  with  or  without 
mustard,  bromide  and  chloral  per  rectum  or  by  mouth,  and  counter- 
irritation  in  the  form  of  a  mustard  plaster  or  mustard-water  cloths 
applied  to  the  spine  from  the  nucha  downward.  Lumbar  puncture  is 
a  sovereign  remedy  in  all  forms  of  cerebral  irritation  associated  with 
increased  intracranial  or  intraspinal  pressure  and  with  the  usual  pre- 
cautions can  safely  be  employed  in  convulsions  failing  to  yield  to 
milder  procedures. 

With  cessation  of  the  convulsions  due  attention  should  also  be  paid 
to  the  more  remote  etiologic  factors,  principally  with  the  view  of 
prophylaxis.  The  diet  should  be  regulated,  the  general  health  im- 
proved, rachitis  promptly  attended  to,  faulty  environment  amelio- 
rated, local  irritations  {e.g.,  phimosis,  adenoids,  foreign  bodies  in  the 
ear  or  nose,  rectal  fissures,  stomatitis,  intense  itching,  etc.)  promptly 
removed,  and  all  such  therapeutic  measures  instituted  as  will  help  to 
counteract  and  eradicate  the  inherent  tendency  to  spasmodic  affections. 

Occasionally  convulsions  in  children  are  met  which  recur  for 
several  years  irrespective  of  all  prophylactic  and  therapeutic  meas- 


DISEASES   OF    THE   NERVE    SYSTEM 


071 


Natrii  BromiJi                                         3  i 

4.00 

Antipyrinae                                               3  ss 

2.00 

Tr.  Aniinoiiii  Yalcrianatis                    3  ii 

8.00 

Syr.  Lactucarii                                       3  iv 

15.00 

Aq.  Auraiitii  Flor.                 q.  s.  ad  f  S  ii 

60.00 

ures,  and  then  suddenly  cease.  In  such  cases  the  cause  will  probably 
be  found  in  some  obscure  disturbance  of  the  endocrine  glands,  giving 
rise  to  some  form  of  autointoxication. 


IJ 


M. 

S. — One  teaspoonful  every  three  to  six  hours, 
for  a  child  two  years  old.  (General  nerve  se- 
dative.) 

II.  Tetanism 

This  term  is  intended  to  denote  a  peculiar  form  of  continued  mus- 
cular hypertonicity  occasionally  observed  in  very  young  infants  with 
markedly  lowered  vitality,  be  it  as  a  result  of  prematurity,  syphilis  or 


Fig.  199. — Tetanism  during  acme  of 
spasm.  Note  characteristic  position  of 
the  extremities. 


Fig.  200. — Tetanism.  Same  case  as 
Fig.  199  during  partial  relaxation  of 
spasm. 


672 


DISEASES   OF   CHILDREN 


chronic  gastroenteritis.  The  onset  of  the  spasticity  is  fairly  rapid, 
and  in  severe  cases,  when  fully  established,  the  posture  assumed  by 
the  patient  is  pathognomonic  (Fig.  199).  The  head  is  moderately  re- 
tracted, the  facial  muscles  are  contracted,  the  jaws  are  firmly  set 
together,  the  forearms  are  flexed  npon  the  arms  and  the  hands  are 
tightly  clenched,  so  as  to  form  firmly  closed  fists.  As  a  rule,  the  legs 
are  bent  angularly  and  the  feet  either  overlap  each  other  or  are 
arched.  The  muscular  contractures  relax  off  and  on  (Pig.  200),  more 
especially  during  profound  sleep,  but  never  subside  entirely.  The 
hypertonicity  increases  on  handling  the  baby,  but  it  never  interferes 
with  feeding.  With  improvement  of  the  general  health  of  the  baby, 
the  contractures  disappear. 

As  may  be  noted  from  the  accompanying  illustrations,  tetanism  is 
a  typical  clinical  picture  easily  to  be  differentiated  from  similar  spas- 
modic affections.    On  the  first  examination  of  the  patient  we  may  sus- 


Fig.  201. — Same  case  as  Fig.  199  three  months  later. 

pect  either  tetany,  tetanus,  or  eclampsia,  but  on  careful  analysis  of  the 
symptomatology  of  the  affections,  the  erroneous  impression  can  read- 
ily be  dispelled.  Tetanism  differs  from  tetany  by  its  more  gradual  de- 
velopment and  almost  continuous  persistence  for  several  months;  any 
kind  of  handling  of  the  baby  increases  its  muscular  hypertonicity, 
while  in  tetany  the  attacks  may  be  brought  about  or  aggravated  only 
by  pressure  upon  large  trunks  of  nerves  or  arteries  (Trousseau's 
phenomenon),  electric  excitability  (Erb's  phenomenon),  or  irritation 
of  the  facial  nerve  (Chvostek's  sign).  Tetanus  is  an  acute  disease, 
preceded  by  an  infection,  as  a  rule  accompanied  by  difficult  degluti- 
tion and  respiratory  embarrassment  and  usually  ending  fatally  within 
a  week.  Eclampsia  infantum  occurs  in  attacks  and  is  associated  with 
loss  of  consciousness.     In  the  same  manner  we  can  promptly  exclude 


DISEASES   OP    THE   NERVE    SYSTEM  673 

so-called  nieningismus;  moreover,  none  of  these  spasmodic  affections 
of  infancy  ever  give  rise  to  the  characteristic  contractures  of  the  ex- 
tremities just  described. 

With  improvement  in  the  general  condition,  the  spasticity  gradu- 
ally (within  a  week  or  a  month  or  longer)  subsides.  Few  babies  in 
that  dilapidated  state  survive,  however,  the  persistent  gastroenteritis 
and  increasing  exhaustion. 

Treatment. — Prophylaxis  and  therapy  the  same  as  in  tetany  (q.  v.) 
except  that  there  is  no  indication  for  the  employment  of  hypnotics. 

III.  Tetany 

This  disease  is  characterized  by  intermittent,  somewhat  painful, 
contraction  of  certain  groups  of  muscles,  especially  of  the  extremities, 
with  exaggeration  of  the  mechanical  and  electric  irritability.  The 
spasm  is  bilateral  and  usually  sets  in  abruptly  without  loss  of  con- 
sciousness. The  hands  assume  a  very  peculiar  shape  greatly  re- 
sembling that  of  holding  a  pen  or  of  making  a  strenuous  et^ort  to 
restrain  a  spirited  horse.  Thus,  the  arms  are  pressed  against  the 
chest,  the  hands  are  bent  on  the  forearms,  the  fingers  are  flexed  upon 
the  palms,  the  phalanges  are  extended,  the  thumbs  are  turned  inward, 
so  as  to  be  covered  by  the  other  fingers,  and  the  wrists  are  flexed  in 
pronation.  When  the  lower  extremities  are  affected,  the  legs  are 
adducted  and  the  plantar  surfaces  of  the  feet  are  strongly  arched, 
with  a  tendency  to  an  equinovarus  position.  Occasionally  the  tetanic 
spasm  extends  to  the  neck  and  back,  and  exceptionally  also  to  the 
laryngeal  and  other  muscles  of  the  body.  On  the  other  hand,  cases 
of  tetany  are  encountered  in  which  the  spasms  are  entirely  wanting 
or  barely  indicated.  These  "latent"  or  passive  forms  of  tetany  may 
frequently  be  brought  into  activity  by  energetic  pressure  upon  the 
main  trunks  of  the  nerves  or  vessels  (e.  g.,  bend  of  elbow).  This  pe- 
culiar mechanical  manifestation  is  spoken  of  as  "Trousseau's  phenome- 
non," and  forms  one  of  the  three  positive  signs  of  tetany — the  so-called 
"triad  of  tetany."  The  other  two  signs  of  tetany  are  those  of  Chvostek 
and  Erb.  " Chvostek 's  phenomenon"  is  based  upon  exaggeration  of  the 
mechanical  irritability  of  the  motor  nerves,  especially  of  the  face  (fa- 
cialis phenomenon),  and  consists  of  lightning-like  contractions  of  the 
face  superinduced  by  percussion  (with  the  finger  or  hammer)  over  a 
branch  of  the  facial  nerve  while  the  face  is  in  a  state  of  perfect  rest. 
"Erb's  phenomenon"  is  based  upon  electric  excitability  of  the  motor 
nerves  and  muscles,  and  Escherich  and  von  Pirquet  maintain  that  we 
have  not  only  a  reaction  or  muscular  response  to  local  cathodal  opening 
and  closure,  but  that  a  current  of  4  ma.  is  sufficient  to  produce  muscular 


674 


DISEASES    OP    CHILDREN 


contraction  or  anodal  closure  and  openinfif  as  well  ''anodal  suscepti- 
bility." 

The  duration  of  the  tetanic  attack  varies  from  a  few  minutes  to 
several  hours  or  longer.  When  they  have  lasted  some  time  there  usually 
develops  edema  of  the  dorsi  of  the  hands  and  feet.  The  spasms  may 
recur  once  or  several  times  daily  or  but  once  in  several  days.  In  the 
great  majority  of  cases  the  disease  usually  subsides  within  a  few  days 
or  a  month  or  two,  without  any  permanent  sequelae,  provided  suitable 
treatment  is  instituted  early.  Zonular  cataract  may  occasionally  form 
a  sequel  of  tetany  and  is  probably  due  to  the  effects  of  faulty  metabolism. 


Fig.   202. — Tetany   in   a   child   eleven   months   old.     Note   characteristic   attitude   of 

liands  and  feet. 


Whe^ther  or  not  the  immediate  cause  rests  upon  functional  or  or- 
ganic disturbance  of  the  thyroid  glands  or  parathyroids  (hemorrhage 
in  the  epithelial  bodies)  is  still  subject  to  great  differences  of  opinion. 
Escherich  and  his  pupils  strongly  favor  this  theory  and  endeavor  to 
prove  that  the  faulty  distribution  of  calcium  was  due  to  interference 


DISEASES    OF    THE    NERVE    SYSTEM  675 

with  the  functions  of  the  parathj'roid.  Rowland  and  Marriott*  insist 
that  enough  studies  have  been  made  to  show  that  parathyroid  lesions 
in  infancy  are  the  exception  and  not  the  rule.  Furthermore,  they 
maintain  that  parathyroid  lesions  as  severe  as  have  been  found  after 
tetany  may  occur  in  patients  who,  during  life,  have  shown  absolutely 
no  evidences  of  this  symptom.  Their  conception  of  tetany  is  that 
some  factor,  at  present  unknown,  causes  a  reduction  of  the  calcium 
content  of  the  blood.  When  this  drops  to  an  amount  roughly  between 
6  and  7  mg.  of  calcium  per  hundred  c.c.  of  serum,  frank  evidences  of 
tetany  arise.  This  amount,  however,  is  not  the  same  with  all  individ- 
uals. With  some  it  may  be  as  low  as  5.5  or  6,  with  others  as  high  as 
7.5.  These  symptoms  occur  in  outbursts  so  long  as  the  calcium  re- 
mains low.  When  the  calcium  rises,  the  symptoms  disappear.  The 
height  to  which  the  calcium  must  rise  in  order  that  the  symptoms 
must  disappear  is  also  somewhat  variable.  Wilson^  and  his  co-workers 
at  the  Johns  Hopkins  Medical  School  found  that,  following  parathy- 
roidectomy in  dogs,  the  equilibrium  between  acids  and  bases  is  dis- 
placed in  favor  of  the  bases,  and  that  in  tetany  developing  after 
such  a  procedure  there  is  well  marked  alkalosis.  The  results  have 
been  confirmed  by  McCann^  at  the  Harvard  Medical  School,  who 
agrees  that  there  is  a  marked  increase  in  the  carbon  dioxid-combining 
power  of  the  blood  plasma,  coincident  with  the  development  of  tetany. 

Treatment. — The  treatment,  especially  with  the  view  of  prophylaxis, 
is  essentially  the  same  as  employed  in  rachitis — corresponding  to  the 
apparent  relationship  that  exists  between  the  pathogenesis  of  rickets 
and  that  of  tetany.  Similar  to  rickets,  tetany  occurs  in  infants  chiefly 
of  a  half  to  two  years  of  age.  Like  rickets  tetany  shows  a  predilection 
for  poorly  fed  and  poorly  housed  children,  and,  finally,  as  in  rickets, 
the  immediate  cause  of  tetany  seems  to  be  some  form  of  intoxication, 
intestinal  or  otherwise. 

The  diet  should  be  regulated,  as  to  quality  and  quantity. 
Young  infants  should,  if  possible,  receive  breast  milk.  The  in- 
testinal tract  should  be  cleansed  with  calomel  by  mouth,  lavage 
and  low  enemas.  For  the  relief  of  severe  contractions  prolonged 
warm  baths,  bromides  and  chloral  will  usually  prove  efficient  (see 
'  *  Rachitis " )  ;  and  in  view  of  the  fact  that  there  is  an  insufficiency 
of  calcium  in  the  blood  and  also  that  in  surgical  parathyreopriva 
calcium   is  found  to   arrest   the   tetanic   spasm,   we   are   fully   justi- 


*IJow!and,  John,  and  Marriott,  W.  McK. ;  Observations  on  the  Calcium  Content  of  the 
Blood  in  Infantile  Tetany  and  on  the  Effect  of  Treatment  with  Calcium.  (Bull.  Johns  Hos- 
kins   Hosp.,   Vol.   xxiv,   p.   235.    1918). 

^Wilson,  D.  W.;  Stearns,  Thornton,  and  Janney,  J.  H.,  Jr.:  J.  Biol.  Chem.  21,  169,  1915; 
Wilson,  D.  W,;   Stearns,     Thornton,  and  Thurlow,   M.   D. :     Ibid.   23,  89,   1915. 

^McCann,  W.  S.:  A  Study  of  the  Carbon  Dioxide-Combining  Power  of  the  Blood  Plasma  in 
Experimental   Tetany,   J.    Biol.    Chem.   35,    553    (Sept.)    1918. 


676 


DISEASES   OF    CHILDREN 


fied  in  favoring  its  administration  also  in  infantile  tetany.  Syr. 
calcii  lactophosphatis  (i/^  dram)  or  calcium  lactatis  (2  grains)  three 
times  daily  are  useful  preparations.  Phosphorus  with  cod  liver  oil 
should  be  g'wen  a  fair  trial. 

Late  or  Puerile  Tetany  is  met  with  in  children  over  three  years,  and 
is  manifested  chiefly  by  carpopedal  spasm  of  brief  duration. 

IV.  Pseudotetanus"  (Escherich) 

This  affection  differs  from  tetanus  principally  by  its  predilection  for 
the  muscles  of  the  trunk,  and  its  afebrile  course;  from  tetany  by  its 
spasticity  being  continuous,  and  from  tetanism  by  the  fact  that  it  at- 
tacks children  of  from  four  to  fourteen  years  of  age  (instead  of  in- 
fants) who  are  apparently  enjoying  perfect  health.  The  pathogenesis 
of  the  disease  is  still  unknown. 

The  patients  (usually  boys)  suddenly  complain  of  stiffness  in  the 
legs  and  inability  to  walk  about.     The  rigidity  rapidly  extends  to 


Fig.   203. — Pseudotetanus.      (After   Pfaundler  and  Schlossmann.) 

the  back  and  head,  so  that  the  patient  lies  motionless  like  a  log,  ex- 
cept for  his  ability  to  make  free  use  of  his  arms  and  hands.  The 
affected  muscles  are  maximally  contracted,  prominent,  and  as  hard  as 
marble.  The  facial  muscles  except  those  of  the  eyes  also  are  in  a 
state  of  tonic  spasm,  so  that  the  facial  expression  is  that  of  trismus, 
the  teeth  are  firmly  set  together  and  barely  separable  with  force. 
Nevertheless,  there  is  but  little  difficulty  in  feeding  the  patient.  The 
rigidity  is  in  partial  abeyance  during  sleep  as  well  as  during  perfect 
rest,  but  greatly  increased — up  to  painful  opisthotonos,  spasm  of  the 
diaphragm,  etc. — by  all  sorts  of  bodily  or  mental  irritations.  During 
the  height  of  the  disease  such  spasmodic  paroxysms  may  occur  also 
spontaneously  several  times  a  day  and  are  usually  followed  by  pro- 
fuse sweating. 


•There  is  considerable  diversity  of  opinion  regarding  the  existence  of  such  a  clinical  entity. 
It   surely   is    of  very   rare    occurrence. 


DISEASES    OF    THE    NERVE    SYSTEM  677 

The  spasmodic  condition  persists  without  apparent  variation  for 
from  jthree  to  six  weeks,  whereupon  the  contractures  gradually  (within 
from  two  to  four  weeks)  abate  never  to  return. 

Treatment. — The  treatment  is  symptomatic.  (See  "Tetany".)  Ga- 
vage,  if  necessary. 

V.  Spasmus  Glottidis 

(Laryngospasm) 

Spasm  of  the  glottis  is  a  disease  of  infants  of  from  six  to  twenty-four 
months  old,  the  age  in  which  rickets  is  most  apt  to  prevail.  It  is  closely 
related  to  and  a  frequent  partial  phenomenon  of  tetany  (usually  shows 
Trousseau's  and  Erb's  signs)  and  seems  also  to  rest  upon  the  identical 
pathogenesis  of  the  latter  disorder. 

The  spasmodic  attack  is  manifested  by  sudden  deep  inspiration, 
dyspnea,  apnea,  pallor  and  later  cyanosis  of  the  face,  fixation  or  rolling 
of  the  eyes,  and  more  or  less  marked  rigidity  of  the  body.  At  the  end 
of  a  few  seconds  breathing  is  res"umed  after  a  noisy  expiration.  In 
severe  cases  the  spasm  not  rarely  extends  to  the  diaphragm  and  to  the 
entire  musculature  of  the  body. 

The  attacks  usually  recur  at  shorter  or  longer  intervals  (several 
times  a  day!),  and,  if  not  terminating  fatally,  which  may  occasionally 
take  place  very  suddenly  even  during  a  simple  attack  as  a  result  of  as- 
phyxia, they  gradually  subside  after  a  few  weeks  or  months.  In  mild 
cases  recovery  is  the  rule.  The  physician  should  be  guarded,  however, 
in  the  prognosis. 

Spasmus  glottidis  can  readily  be  distinguished  from  other  forms  of 
laryngeal  stenosis  (e.  g.,  retropharyngeal  abscess)  by  its  intermittency 
and  noiselessness,  between  each  attack.  It  should  not  be  confounded 
with  the  momentary  apnea  ("holding  the  breath"),  frequently  ob- 
served in  children  during  a  fit  of  crying.  (See  "Congenital  Stridor" 
and  "Thymus  Hypertrophy",) 

Treatment. — As  the  physician  rarely  has  the  opportunity  to  witness 
an  attack  of  laryngospasm,  his  efforts  must  be  directed  chiefly  toward 
its  prevention.  This  is  best  accomplished  by  antirachitic  treatment 
iq.v.),  including  calcium,  careful  attention  to  the  alimentary  tract,  and 
calming  of  the  irritability  by  means  of  small  doses  of  sodium  bromide. 
(See    "Eclampsia".)       Severe    attacks    call    for    stronger    hypnotics. 

A  severe  attack  may  sometimes  be  aborted  by  dashing  cold  water  in 
the  child's  face,  exciting  choking  motions  by  pressure  upon  the  root  of 
the  tongu^e,  and  exciting  sneezing  by  irritating  the  nasal  mucous  mem- 
brane.    In  some  cases  light  ethyl  chloride  or  ethyl  bromide  anesthesia 


678  DISEASES    OF    CHILDREN 

may  be  tried.     Timely  intubation  and  artificial  respiration  have  saved 
some  babies  from  immediate  death. 

Chorea  Vera 

(St.  Vitus 's  Dance,  Chorea  Minor,  Sydenham's  Chorea) 

Genuine  chorea  is  an  acute,  infectious,  sporadic  and  epidemic  affec- 
tion characterized  by  spontaneous,  irregular  movements  of  the  vol- 
untary musculature,  and  by  a  special  tendency  toward  cardiac  com- 
plications. 

The  specific  causal  microorganism  of  this  disease  is  still  vmknown, 
but  is  probably  closely  related  to  that  of  rheumatic  affections,  with 
which  chorea  is  occasionally  associated.  Other  infectious  diseases 
(such  as  exanthemata),  fright  and  mental  overwork  serve  as  predis- 
posing causes. 

The  onset  of  chorea  is  preceded  by  prodromata  varying  in  duration 
from  a  few  hours  to  a  few  days.  They  consist  of  fretfulness,  fatigue, 
pain  in  the  extremities,  restless  sleep  and  occasional  twitching.  After 
the  prodromic  stage  the  actual  attack  may  be  precipitated  abruptly 
and  with  full  force,  or  come  on  gradually  and  run  a  mild  course.  The 
cardinal  symptoms  of  the  disease  are  irregular,  awkward,  involuntary, 
muscular  movements — hasty  and  beyond  control — which  cease  only 
during  sound  sleep.  The  movements  intermittently  involve  various 
sets  of  muscles  never  letting  up  a  moment  while  the  patient  is  awake. 
The  movements  are  intensified  when  the  patient  is  conscious  of  being 
observed,  and  tries  to  control  them,  or  attempts  to  perform  some 
voluntary  action.  The  shoulders,  one  or  both,  jerk  upward  or  down- 
ward, the  arms  rotate  from  side  to  side,  or  are  forcibly  thrown  back- 
ward, the  hands  are  engaged  in  incomplete  extension,  flexion,  prona- 
tion or  supination,  while  the  fingers  are  bent,  extended  or  shoved 
one  over  the  other  so  that  the  patient  is  unable  to  hold  an  object 
firmly,  to  write,  to  button  a  garment,  etc.  The  head  sways  from  side 
to  side,  often  describing  a  semicircle,  or  is  dropped  downward  so  that 
the  chin  touches  the  chest  wall.  The  facial  muscles  twitch,  and  pro- 
duce grotesque  distortions  of  the  face  and  mouth.  The  forehead  is 
wrinkled,  the  eyes  open  and  close,  the  patient  seeming  to  cry  or  laugh. 
In  one  case  under  our  observation  the  iris  (!)  was  involved  so  that 
the  pupils  contracted  and  dilated  almost  incessantly.  The  tongue 
participates  in  the  movements,  causing  difficulty  in  eating  and  drink- 
ing, and  defective  speech  up  to  aphasia.  The  movements  of  the  lower 
extremities  vary  with  the  intensity  of  the  attack,  in  severe  cases  be- 


DISEASES    OF    THE    NERVE    SYSTEM  671) 

ing  of  such  nature  that  the  patient  is  unable  to  stand,  sit  or  lie  still,  and 
frequently  falls,  stumbles,  or  is  thrown  out  of  bed  and  injured.  Dur- 
ing the  acme  of  the  attack  it  is  not  uncommon  to  find  irregular  res- 
piration and  arrhythmia  of  the  pulse — both  from  implication  of  the 
respiratory  muscles  and  the  heart  {chorea  cordis).  However,  notwith- 
standing the  intensity  of  the  movements  the  patients  rarely  complain 
of  being  fatigued,  in  fact  a  great  many  children  seem  otherwise  in  per- 
fect health.  The  temperature  is  normal,  the  digestion  good,  sensory 
disturbances  are  usually  rare  and  slight  (hyperesthesia  along  the  course 
of  the  nerve  trunks),  the  patellar  reflex  is  somewhat  exaggerated,  but 
the  cutaneous  sensibility  and  reflexes  are  unaltered. 

If  left  untreated  the  active  stage  of  the  disease  lasts  from  four  to  six 
weeks;  then  the  symptoms  gradually  diminish  and  may  disappear  en- 
tirely a  few  weeks  later.  Some  cases  run  a  mild  course  from  beginning 
to  the  end,  at  no  time  presenting  the  aforementioned  grotesque  muscular 
excursions.  This  is  especially  prone  to  occur  if  treatment  is  begun 
early,  and  persisted  in. 

The  intensity  of  the  attack  stands  in  no  relation  to  its  duration;  on 
the  contrary,  cases  of  slow  development  and  moderate  severity  may 
run  a  chronic  course  and  suffer  relapses,  while  violent  cases  often 
respond  to  a  few  weeks'  treatment.  This  incongruity  is  often  ob- 
served also  as  regards  complications ;  mild  cases  being  not  rarely 
associated  with  fever,  inflammation  of  the  joints,  pleura,  pericardium 
or  endocardium,  whereas  severe  chorea  may  run  its  course  without 
any  untoward  results.  In  reference  to  heart  complications  which  is 
supposed  to  occur  in  about  20  per  cent  of  cases,  it  is  well  to  remember 
that  not  every  blowing  heart  sound  heard  in  chorea  is  indicative  of 
valvular  lesion;  the  majority  of  these  adventitious  sounds,  especially 
those  heard  at  the  base,  disappear,  perhaps,  never  to  return.  On  the 
other  hand,  heart  lesions  have  been  found  at  the  autopsy  without  any 
indications  of  their  presence  during  life,  a  fact  which  strongly  em- 
phasizes the  necessity  of  prophylactic  measures  (perfect  rest)  being 
taken  against  heart  disease  during  the  active  stage  of  the  disease. 

Sometimes  the  muscular  disturbance  is  limited  to  one-half  of  the 
body  {heniiichorea) ,  showing  that  the  lesion  is  localized  in  one  hemi- 
sphere of  the  brain.  This  form  of  chorea  is  more  serious  than  bilateral 
chorea.  It  is  often  associated  with  paresis  of  the  extremities,  one  or 
both  (chorea  paralytica;  chorea  mollis),  and  changes  in  the  psychical 
condition,  e.  g.,  melancholy,  hallucinations. 

Notwitrhstanding  the  grave  nature  of  the  affection,  the  prognosis  of 
chorea,  on  the  whole,  is  favorable.     A  fatal  termination  is  exceptional. 


G80  DISEASES   OF    CHILDREN 

This  may  occur  either  as  a  result  of  complicating  heart  disease,  or  from 
some,  as  yet  unknown,  effect  upon  the  central  nerve  system.  To  the 
latter  class  belong  the  cases  associated  with  delirium  and  prostration 
(chorea  insaniens).  On  the  other  hand,  the  prognosis  as  to  permanent 
recovery  is  not  quite  promising.  Recurrences  are  frequent,  and  as  pre- 
viously mentioned,  the  tendency  to  permanent  heart  disease  is  great. 

Treatment. — With  these  facts  in  view,  the  urgency  of  instituting 
preventive  measures  against  chorea  is  obvious.  This  is  strongly  em- 
phasized by  the  observation  that  chorea  may  appear  in  epidemic  form 
(it  is  quite  common  to  tind  several  members  of  one  family  to  be  at- 
tacked simultaneously  or  within  a  brief  period  of  time).  I  am  not 
referring  to  the  hysterical  ''pseudochorea"  not  rarely  encountered  in 
epidemic  form  in  girls'  boarding  schools.  (See  "Hysteria".)  Pro- 
phylaxis is  best  accomplished  by  isolation  of  the  patient.  This  is 
imperative  in  hospitals,  asylums  or  private  schools  wdiere  several 
inmates  are  congregated  in  close  quarters.  Girls,  between  six  and 
twelve  years  of  age  particularly,  should  be  kept  apart,  as  they  are 
very  susceptible  to  chorea:  about  70  per  cent  of  the  cases  are  met 
in  girls,  probably  because  of  their  poorly  developed  body  musculature. 
In  recurrent  chorea  the  teeth,  tonsils  and  adenoids  should  be  looked  after. 

The  active  treatment  consists  principally  of  perfect  rest  in  bed  in 
an  airy  and  sunny  room,  and  avoidance  of  all  mental  excitement. 
While  the  choreic  movements  are  very  pronounced,  the  patient  should 
be  kept  in  a  well-padded  bed  (to  avoid  injury)  day  and  night,  but,  as 
the  symptoms  improve,  she  may  be  allowed  to  sit  up  or  be  around  and 
about  for  a  few  hours  at  a  time.  A  warm  bath  with  a  cool  sponge 
once  or  twice  a  day  and  a  daily  colon  flushing  are  very  salubrious. 
The  food  should  be  bland,  nutritious,  and  preferably  liquid  or  semi- 
solid (milk,  cereals,  broths,  fruit  juice,  etc.),  especially  when  mastica- 
tion and  degulutition  are  difficult.  Arsenic  in  the  form  of  Fowler's 
solution  is  the  remedy  par  excellence  in  all  cases  of  chorea,  except  when 
associated  with  marked  paresis.  It  should  be  begun  with  in  Yo  drop 
doses  for  every  year  of  the  child's  age,  and  increased  by  i/^  a  drop 
every  other  day.  Should  the  urine  show  the  presence  of  albumin, 
the  lids  become  puffy,  the  stomach  irritated  (pain  or  ifausea),  it  is 
advisable  to  go  back  to  the  original  dose,  or  to  discontinue  it  entirely 
for  a  few  days.  In  the  so-called  paralytic  cases  the  cacodylates  of 
arsenic,  strychnine  and  glycerophosphates,  administered  either  by 
mouth  or,  preferably,  hypodermically,  often  act  exceedingly  well. 
Whenever  sore  throat  or  rheumatic  pain  has  preceded  the  attack  of 
chorea,  the  salicylates,  with  or  without  digitalis,  should  be  pushed  to 
full  tolerance.     During  the  acme  of  the  disease,  the  bromides,  and 


DISEASES   OF    THE    NERVE    SYSTEM  681 

more  powerful  hypnotics,  if  needed,  will  be  found  to  act  kindly  in  re- 
ducing the  severity  of  the  choreic  movements,  allaying  the  nerve  irri- 
tability and  inducing  sleep — all  of  which  being  essential  to  the  recovery 
and  maintenance  of  the  strength  of  the  patient.  In  very  grave  cases 
chloroform  anesthesia,  may  very  cautiously  be  resorted  to.  Many 
years  ago  I  reported  a  number  of  cases  of  protracted  chorea  Avhich 
were  greatly  benefited  by  lumbar  puncture.  The  suggestion  recently 
made  to  inject  an  autogenous  blood  serum  into  the  spinal  canal  has 
failed  to  meet  with  favor.  The  same  holds  true  for  the  intraspinal 
injection  of  magnesium  sulphate.  Finally  it  is  well  to  bear  in  mind 
that  a  number  of  cases  Avill  run  their  course,  uninfluenced  by  any 
method  of  treatment,  and  possibly  be  harmed  by  overtreatment.  In 
refractory  cases  we  may  try  a  milk-  and  meat-free  diet,  for  a  week 
or  two. 

IJ     Liq.  Potassii  Arsenitis  I 

Aq.  Aurantii  Flor.  aa  3  ii     |      8.00 
M. 

S. — Begin  with  one  drop  for  every  year  of  the 
child's  age  and  increase  by  one  drop  every  other 

day,  up  to  full  tolerance.  To  be  well  diluted  in 
water. 


n 

Natrii  Salicyl 

Natrii  Bromidi                               aa  3  i  ss 

6.00 

Mist.  Rhci  et  Sodae                              3  iv 

15.00 

Aq.  Destil.                               q.  s.  ad  f  3  ii 

60.00 

M. 

S. — One   tcaspoonful   every   four   to   six  hours, 

for  a  child  six  years  old. 

r^ 

Ferri  Sulph.  Exs.                                  gr.  x 

0.60 

Pulv.  Chocolate                                         3  i 

4.00 

M,     Div.  in  pulv.  no.  xx. 

S. — One  powder  after  each  meal. 

Habit  Spasm 

(Tic) 

Children  of  a  nervous  temperament  quite  frequently  acquire  the 
habit  of  spasmodically  moving  the  head  (swaying,  rolling  or  nod- 
ding), face  (tic),  fingers  and  hands,  which,  if  not  immediately  stopped 
by  strict  discipline,  is  apt  to  persist  for  weeks  and  months.  In  some 
cases  the  bad  habit  is  traceable  to  faulty  wearing  apparel.  For  ex- 
ample, head  nodding  in  girls  from  poorly  fitting  hats,  head  swaying 
in  boys  fcom  a  too  tightly  fitting  collar,  etc.  Habit  spasm  should  not 
be  confounded  with  chorea.  v 


682  DISEASES   OF    CHILDREN 

A  similar  spasmodic  condition  has  been  described  ])y  Henoch  as 
"chorea  electrica."  It  occurs  in  children  from  nine  to  fifteen  years 
old,  in  the  form  of  lightning-like  spasms,  especially  of  the  neck  and 
shoulders,  as  though  produced  by  a  galvanic  current.  This  spasm 
seems  to  be  identical  with  '^paramyoclonus  multiplex"  (a  neurosis 
marked  by  shock-like  muscular  contractions,  which  are  bilateral  and 
do  not,  as  a  rule,  affect  the  hands  and  face)  but  may  be  hysterical 
in  nature.    Electricity  does  well  in  these  cases,  probably  by  suggestion. 

Spasmus  Nutans 
(Spasmus  Rotatorius,  Head  Nodding) 

The  disease  in  question  is  of  obscure  origin.  It  is  usually  seen  in 
infants  of  from  four  to  eighteen  months  of  age,  chiefly  in  those  suffer- 
ing from  rachitis.  The  spasmodic  movements  are  generally  limited  to 
the  muscles  innervated  by  the  cervical  plexus  and  the  accessory  nerve, 
notably  the  recti  capitis,  longus  colli,  scaleni  and  sternocleidomastoid. 
In  consequence  of  the  irritation,  the  head  rotates  from  side  to  side  or 
shakes  anteroposteriorly  at  a  variably  rapid  (every  second)  pace, 
with  occasional  interruption,  but  ceases  entirely  only  during  sleep  or 
temporarily  while  blindfolded  (Caille).  The  head  nodding  is  usually 
associated  with  nystagmus  and  more  rarely  strabismus  or  rolling  of 
the  eyeballs.  In  some  cases  some  etiologic  relation  seems  to  exist  be- 
tween spasmus  nutans  and  visual  disturbance,  but  Avhether  the  defect 
be  in  the  muscle  or  nerve  supply  is  still  a  matter  of  conjecture. 
Henoch  attributes  the  association  of  the  nystagmus  with  the  rotatory 
movements  of  the  head  to  the  close  proximity  of  and  extension  of  irri- 
tation from  the  ocular  nuclei  to  the  nuclei  of  the  nerves  and  muscles 
which  rotate  the  head. 

The  spasmodic  movements  gradually  disappear  in  the  course  of  a 
few  weeks  or  months,  after  improvement  in  the  general  health.  (See 
Rachitis.) 

Spasmus  nutans  may  be  confounded  with  "juvenile  congenital 
nystagmus"  (associated  with  marked  visual  defects,  e.g.,  disease  of 
the  retina,  lens,  etc.)  ;  with  brain  disease  which  can  readily  be  recog- 
nized by  the  concomitant  symptoms,  and  with  "epilepsia  nutans"  {q.  v.). 

Hysteria 

Hysteria  is  a  neuropsychosis,  a  product  of  faulty  environment  and 
education.*  It  is  rare  in  children  under  eight  years  of  age,  but  quite 
common  in  older  ones,  especially  in  girls. 


'Sheffield,  IT.   B  :     A   Contribution   to   the    Study   of   Hysteria   in   Children.      (New   York  Med. 
Jour.,    September   17   and   24,    1898.) 


DISEASES   OF    THE   NERVE   SYSTEM  68-3 

The  onset  of  lij^steria  can  frequently  be  traced  to  some  sudden  vio- 
lent emotion  (shock)  with,  or  more  rarely,  without  bodily  injury. 
The  attendant  circumstances  at  the  time  of  the  psj'chic  disturbance 
often  serve  to  determine  the  seat  of  the  hysterical  lesion,  c.  g.,  hysteri- 
cal deafness  after  an  explosion,  paralysis  or  contracture  of  an  extremity, 
after  a  trivial  injury. 

The  symptomatology  of  hysteria  is  characteristic  for  its  multiplicity 
and  mutability.  It  may  closely  simulate  that  of  any  organic  disease, 
but  its  spuriousness  can  usually  be  detected  after  careful  scrutiny. 
The  diagnostic  perplexities  augment,  hoAvever,  with  accidental  con- 
currence of  some  acute  affection  or  preexistence  of  a  chronic  organic 
disease. 

Paralysis  of  the  extremities  with  or  without  contracture  forms  a 
frequent  hysterical  manifestation.  It  may  appear  in  the  form  of  para- 
plegia, monoplegia,  or  hemiplegia,  and  thus  resemble  myelitis,  polio- 
myelitis, or  cerebral  paralysis.  In  hysterical  "spinal"  paralysis,  how- 
ever, there  is  rarely  absolute  loss  of  muscular  power.  Muscular 
atrophy  is  absent  or  slight,  and  electric  irritability  remains  normal. 
In  hysterical  "cerebral"  paralysis,  also,  the  loss  of  power  is  rarely 
complete  and  the  leg  is  often  more  affected  than  the  arm.  The  face 
usually  remains  uninvolved.  A  peculiar  form  of  either  continuous  or 
intermittent  pseudoparalysis  is  occasionally  met  with  in  children, 
which  has  been  described  by  Blocq  as  "astasia-abasia."  In  this  con- 
dition the  muscles  of  the  lower  extremities  can  be  freely  used  except 
in  standing  or  walking.  If  the  latter  is  attempted,  the  patient  im- 
mediately falls  to  the  ground  or  begins  to  tremble  and  topples  over, 
or  manifests  ataxic  sympoms  (cerebellar  type).  The  difficulty  in 
walking  is  sometimes  overcome  after  a  few  steps  are  taken. 

The  hysterical  contractures  may  involve  the  articulations,  groups 
of  muscles  or  a  part  of  a  muscle.  As  a  rule,  the  joints  of  the  tapering 
extremities  are  most  frequently  affected.  All  sorts  of  deformities 
may  arise  which  may  greatly  resemble  genuine  joint  and  bone  dis- 
ease (e.  g.,  hip-joint  disease,  spondylitis,  talipes,  etc.)  and  lead  to 
errors  in  the  diagnosis.  The  more  sudden  onset,  the  irregularity  of 
its  course,  the  tendency  to  change  its  situation  and  the  concomitance 
of  other  evidences  of  hysteria,  all  help  the  exclusion  of  organic  disease. 
At  a  later  stage  the  diagnosis  of  hysterical  contracture  can  frequently 
be  made  by  the  absence  of  local  thickening,  or  active  inflammation  of 
the  bone  or  muscle  and  its  disappearance  under  anesthesia.  Where 
part  of  a  muscle  is  affected  the  contracture  may  give  rise  to  circum- 
scribed swellings.  Allied  in  nature  are  also  the  so-called  "phantom 
tumors"  occasionally  observed  on  the  lower  portion  of  the  abdomen. 


684 


DISEASES   OF    CHILDREN 


and  the  peculiar  "ballooning"  of  the  hypogastrium  manifested  with 
each  expiration.  Occasionally  the  abdominal  enlargement  is  general 
and  not  rarely  accompanied  by  local  tenderness.  Furthermore,  the 
hysterical  tympanites  may  be  associated  with  vomiting,  anorexia, 
singultus,  disturbed  respiration,  retention  of  urine,  etc.,  and  thus  give 
rise  to  the  clinical  picture  of  peritonitis,  which  may  test  the  skill  of 
even  the  best  diagnostician.     As  a  rule,  obstipation  and  fever  are  ab- 


Fig.  204. — Hysterical  phantom  tumor  of  tlie  abdomen. 

Schlossmann.) 


(Aftei  Pfaundler  and 


sent  in  these  cases  and  the  vomiting  is  not  so  persistent  as  in  true  peri- 
tonitis. Of  course,  vomiting,  anorexia,  tachypnea,  etc.,  may  exist 
independently  of  the  hysteria  and  greatly  obscure  the  diagnosis. 

The  symptoms  thus  far  enumerated  represent  principally  the  neu- 
rotic element  of  hysteria.     To  those  may  be  added  the  occasionally 


DISEASES   OF    THE    NERVE    SYSTEM  G85 

occurring  cataleptic  states,  spasms  of  the  laryngeal  muscles  (croup), 
dysphagia,  aphasia,  aphonia,  with  spells  of  coughing,  singing,  or  stut- 
ering,  asthma,  amblyopia,  hemianopsia,  contraction  of  the  visual  field, 
amaurosis,  and  blepharospasm. 

In  another  group  of  cases  the  psychic  element  predominates.  Here, 
too,  however,  there  is  generally  a  great  display  of  spasmodic  and  con- 
vulsive movements  ranging  between  simple  or  choreic  tremor  to 
marked  epileptiform  convulsions  (hysteroepilepsy).  The  movements 
may  assume  the  form  of  athletic  exercises,  such  as  rowing,  swimming, 
punching,  etc. — chorea  rhythmica;  or  the  patient  may  act  as  though 
possessed,  climb  walls,  turn  somersaults,  and  perform  all  sorts  of  stunts 
■ — chorea  magna.  Still  more  advanced  cases  of  hysteria  may  be  mani- 
fested by  attacks  of  sopor,  night  terrors,  somnambulism,  hallucinations, 
delirium  and  mania.  Hammond,  in  his  treatise  on  "Spiritualism" 
(1876),  refers  to  several  journalistic  reports  of  epidemics  of  hysteria 
as  they  occurred  in  this  country  two  centuries  and  more  ago.  One  of 
the  first  documents  of  this  kind  appeared  in  a  New  England  paper,  in 
1688,  and  reads  as  follows : 

Four  children  of  John  Goodwin,  of  Boston,  remarkable  for  their  piety,  honesty, 
and  industry,  were  in  the  year  1688  made  the  subject  of  witchcraft.  The  eldest,  a 
girl  about  thirteen  years  old,  had  a  dispute,  about  some  linen  that  was  missing,  with 
a  laundress  whose  mother,  a  scandalous  Irishwoman  of  the  neighborhood,  applied 
some  abusive  language  to  the  child.  The  latter  .was  at  once  taken  with  "odd"  fits 
which  carried  in  them  something  diabolical.  Boon  afterward  the  other  children,  a 
girl  and  two  boys,  became  similarly  affected.  Sometimes  they  were  deaf,  sometimes 
they  were  blind,  sometimes  dumb,  and  sometimes  all  of  these.  Their  tongues  would 
be  drawn  down  their  throats,  and  then  pulled  out  upon  their  chins  to  a  prodigious 
length.  Their  mouths  were  often  open  to  such  an  extent  that  their  jaws  were  dis- 
torted and  were  then  suddenly  closed  with  a  snap  like  that  of  a  spring  lock.  The 
like  took  place  with  their  shoulders,  elbows,  wrists  and  other  joints.  They  would 
lie  in  a  benumbed  condition  and  be  drawn  together  like  those  tied  neck  and  heels, 
and  presently  be  stretched  out,  and  then  be  drawn  back  enormously.  They  made 
piteous  outcries  that  they  were  cut  with  knives,  and  struck  with  blows,  and  the  plain 
prints  of  wounds  were  seen  upon  them.  At  times  their  necks  were  rendered  so 
limber  that  the  bones  could  not  be  felt,  and  again  they  were  so  stiff  that  they  could 
not  be  bent  by  any  degree  of  force. 

The  next  authentic  account  is  offered  by  Eev.  Dr.  Davidson.*  While  relating  the 
proceedings  of  a  Kentucky  camp  meeting,  in  the  year  1800,  the  writer  remarks  that 
"small  children  had  taken  part  in  the  religious  ceremonies,  which  consisted  in  part 
in  the  following  feats:  Simple  jerking  of  the  arms  from  the  elbow  downward.  The 
head  was  thrown  backward  with  a  celerity  that  alarmed  spectators,  causing  the  hair, 
if  it  was  long,  to  crack  and  snap  like  the  lash  of  a  whip.  The  children  would  bounce 
from  place  to  place  like  a  foot  ball,  or  hop  around  with  head,  limbs  and  trunk, 

*History  of  the   Presbyterian   Church  in   Kentucky. 


686  DISEASES    OF    CHILDREN 

twitching  and  jolting  in  every  direction.  Sometimes  the  head  would  be  twitched 
right  and  left  to  a  lialf  round  with  such  velocity  that  not  a  feature  could  be  dis- 
cerned. ' ' 

This  hysterical  method  of  worshiping  seems  to  have  been  "contagious"  in  char- 
acter, for  about  the  same  time  several  such  epidemics  are  recorded,  foremost  of 
which  is  that  reported  by  Rev.  John  Wilkinson,*  who  realized  the  morbid  basis  of 
the  religious  ceremonies.  It  may  be  noted  here  that  this  contribution  on  liysteria 
seems  to  be  the  first  one  ever  published  in  an  American  medical  paper.  "Tins 
disease,"  the  divine  begins,  "made  its  appearance  early  in  the  summer  of  1803, 
and  increased  in  its  effects  with  astonishing  rapidity  until  the  latter  end  of  that 
season.  I  have  known  some  persons  as  young  as  six  or  seven  years  of  age,  and 
others,  I  think,  upward  of  sixty  affected  *  *  *  There  is  scarcely  one  girl  in 
ten  between  the  age  of  ten  to  twenty  that  has  not  had  or  now  has  the  exercise 
*  *  *  The  paroxysms  continued  from  a  half  an  hour  to  an  hour  and  upward.  The 
agitation  consisted  in  twitching,  retching,  groaning,  jerking  and  laughing.  Pre- 
monitory symptoms  were  compression  or  weight  in  the  chest  or  about  the  heart. 
The  motion  gave  relief.     No  other  complaints  of  corporeal  pains  were  made. 

They  all  agree  in  asserting  that  during  these  exercises  the  senses  remain  in  full 
vigor,  and  that  even  in  their  silent  exercises  they  know  everything  that  is  passing 
about  them.  They  also  say  that  their  mental  faculties  during  the  paroxysms  are 
preternaturally  active  and  strong  *  *  *  When  a  person  is  in  the  silent  exercise, 
if  a  pin  or  a  needle  be  introduced  through  the  skin,  it  will  cause  no  emotion  or 
complaint,  but  will  produce  the  sensation  of  pain. ' ' 

Epidemics  of  this  kind  occurred  also  in  1835,  1846,  and  1870,  but 
for  the  sake  of  brevity  we  will  omit  their  full  discussion. 

Hysteroepilepsy  is  comparatively  rare  in  children.  An  attack  is 
usually  preceded  by  emotional  excitement,  globus  hystericus,  etc.,  and 
may  be  induced  by  pressure  upon  sensitive  areas — hysterogenic  zones 
— of  the  body,  such  as  the  hypochondriac  or  spinal  regions.  Hystero- 
epilepsy differs  from  genuine  epilepsy  in  the  following  respects : 

Epilepsy  Hysteroepilepsy 

Onset  sudden  Preceded  by   emotional   excitement 

Consciousness  entirely  lost  Partially  preserved 

Convulsions  preeminently  clonic  Tumultuous,    accompanied    by    moaning, 

Duration  short,  followed  by  stupor  screaming,  crying,  etc. 

Longer;   followed  by  restlessness 

Hysteria  generally  proceeds  a  very  chronic  course,  with  temporary 
improvement  and  relapses.  Of  course,  it  very  much  depends  upon  the 
etiologic  factors,  the  time  when  treatment  is  begun  and  the  energy 
with  which  it  is  carried  out. 

Without  denying  the  transmissibility  from  parent  to  offspring  of  a 
certain  degree  of  nerve  instability  Avhich  may  predispose  to  hysteria, 

•Philadelphia    Med.    and    Phys.    Journal,    pp.    87-96,    1805. 


DISEASES    OF    THE    NERVE    SYSTEM  G87 

in  the  great  majority  of  instances  this  disease  is  acquired  as  a  result 
of  harmful  influences  of  faulty  environment  and  education.  A  child 
repeatedly  seeing  its  mother,  for  example,  in  a  state  of  emotional  ex- 
citement or  frenzy,  sooner  or  later,  consciously  and  deliberately,  or 
otherwise,  learns  to  imitate  its  mother's  hysterical  performances,  the 
habit  of  imitation  gradually  leading  to  aberration  of  the  normal  cere- 
bral functions.  Unaljle  as  the  mother  is  to  control  her  own  abnormal 
actions  and  feelings,  she  can  hardly  be  equal  to  the  occasion  to  guide 
her  children  in  the  right  direction.  On  the  contrary,  the  child  is  al- 
lowed to  have  its  own  way,  is  made  the  central  figure  of  the  house- 
hold and  spoiled  by  overtenderness.  If,  in  addition,  such  methods 
of  education  are  adopted  as  will  overtax  the  child's  mental  capacity 
(e.  g.,  the  study  of  music,  painting,  emotional  recitations,  etc.,  in  addi- 
tion to  arduous  school  work),  a  deranged  state  of  mind  sooner  or  later 
supervenes  Avhich  is  most  susceptible  to  the  aforementioned  pernicious 
influences.  Less  potent  in  the  predisposition  to  hysteria  are  the  use 
of  alcoholic  beverages,  acute  infectious  diseases,  prolonged  disturb- 
ance of  sexual  (masturbation!),  digestive  and  circulatory  (anemia) 
systems,  in  fact,  anything  that  will  undermine  the  physical  or  mental 
condition  of  the  child. 

Treatment. — With  these  principal  etiologic  facts  in  view,  the  indi- 
cations for  the  treatment  of  hysteria  in  children  are  self-evident.  The 
patient  should  be  removed  from  the  hysterical  environments,  and 
placed  under  the  care  of  one  who  with  kindness  but  firmness  can  con- 
trol his  destiny.  Change  of  residence  from  the  noisy  city  to  the  rest- 
ful country  often  works  wonders.  The  child  should  lead  an  outdoor 
life,  and  every  effort  should  be  made  to  raise  his  general  bodily  de- 
velopment. The  food  should  be  ample  and  nutritious,  free  from  al- 
coholic beverages.  Milk  foods  should  be  given  preference  to  meats. 
The  education  should  be  restricted  to  the  simplest  school  work,  or, 
for  a  time  at  least,  entirely  suspended. 

The  active  treatment  of  hysteria  is  essentially  symptomatic.  Warm 
baths  and  cold  showers  and  general  massage  are  useful  in  all  cases. 
Paralysis  and  contractures  frequently  yield  to  electricity,  its  action 
being  probably  suggestive  in  nature.  Suggestion  by  electricity  or 
other  spectacular  procedures  are  also  effective  in  relieving  local  con- 
ditions, such  as  aphonia,  stuttering,  blindness,  and  the  like.  Hystero- 
epilepsy  and  maniacal  outbreaks  call  for  isolation,  rest  in  bed,  and 
the  administration  of  small  doses  of  the  bromides  and  valerian.  Disre- 
gard of  the  patient's  complaints  and  severity  will  often  cure  some 
hysterical  phenomena  where  kinder  therapeutic  measures  ordinarily 
fail. 


688 


DISEASES   OF    CHILDREN 


;     Natrii  Bromidi 

3i 

4.00 

Ext,  Humuli  Fl, 

3  iij 

12.00 

Infusi  Valeriana:;  Rad, 

Aq.  Aurantii  Flor. 

a  a  5  j 

.^o.oo 

M. 

S. — One   teaspoonful 

every 

four   hours 

,    for    a 

child  ten  years  old. 

Dystonia  Musculorum  Deformans 

(Progressive  Torsion  Spasm  of  Childhood) 

At  a  meeting  of  the  Berlin  Psychiatric  Society,  December  17,  1910, 
Ziehen^  demonstrated  a  child  ten  years  of  age  with  a  spasmodic  affec- 


Fig.    205. — Progressive   torsion   spasm.      (J.    Ramsey   Hunt.) 

tion  of  unusual  type.  Four  similar  cases  had  come  under  his  obser- 
vation, three  in  members  of  the  same  family.  In  all,  the  affection  had 
been  gradually  progressive  and  was  characterized  by  spasm  and  hy- 
pertonicity  of  the  musculature,  with  curious  twisting  and  torsion  move- 
ments of  the  extremities  and  trunk.  The  muscular  spasm  was 
considerably  increased  by  active   movement  and   diminished  during 


iZiehen:     Tonic    Torsions     (Neurol.     Centralbl.,    xxx,    1909;    Allg.    Ztschr.    f.    Psychiat.     1911, 
Ixviii,   281.) 


DISEASES    OF    THE    NERVE    SYSTEM  689 

rest.  The  gait  and  station  were  ehietly  aiTected  and  there  was  marked 
lordosis  of  the  spine.  The  tendon  reflexes  were  present  but  difficult 
to  elicit,  because  of  the  tension  and  torsion  of  the  muscles.  Sensation 
and  intelligence  were  not  affected,  and,  in  one  of  the  cases,  necropsy 
had  revealed  no  essential  lesion.  All  the  patients  were  Russian  Jews. 
Since  then  numerous  cases  of  this  affection  have  been  reported  by 
J.  Ramsey  Hunt,*  wlio  made  a  special  study  of  the  subject  in  tliis 
country. 


*.Tour.  A.  M.  A.,  Nov.   11,   1916. 


CHAPTER  XIII 

,     AMENTIA 

IDIOCY  AND  THE  ALLIED  MENTAL  DEFICIENCIES 

I.  In  Infancy  and  Early  Childhood 
Nature  and  Pathogenesis 

Amentia  is  not  an  affection  sui  generis,  a  precise  morbid  entity,  but 
merely  a  syndrome  of  a  large  group  of  congenital  and  acquired  patho- 
logic conditions,  principally  of  the  brain  and  the  ductless  glands.  The 
degree  of  mental  debility  is  very  variable  and  not  rarely  incommen- 
surate with  the  extent  and  gravity  of  the  causal  organic  lesion.  I  Thus, 
profound  idiocy  is  frequently  encountered  with  seemingly  i^ignifi- 
cant  structural  changes  in  the  brain  or  elsewhere,  and  vice  versa, 
gross  brain  lesions  may  occasionally  be  accompanied  by  only  slight 
feeblemindedness.  As  a  rule,  however,  definite  postmortem  findings, 
with  predominance  of  characteristic  lesions  in  certain  types  of  cases 
are  observed  in  the  great  majority  of  cases  of  amentia,  so  much  so,  as 
to  permit — in  accord  with  the  underlying  pathologic  anatomy — to 
classify  idiocy  and  the  allied  mental  deficiencies  into  distinct  groups 
(e.  g.,  idiocy  with  microcephalus,  hydrocephalus,  athyrosis,  etc.),  which 
will  presently  receive  due  consideration. 

In  almost  all  forms  of  amentia  the  cerebral  convolutions  are  more 
or  less  modified  and  irregular  in  outline  and  diminished  in  number. 
They  are  either  agglutinated  or  separated  by  widely  gaping  grooves. 
Frequently  there  is  an  appreciable  difference  in  the  size,  shape  and 
weight  of  the  hemispheres,  or  an  asymmetry  of  the  corpora  striata,  the 
peduncles,  or  the  pyramids,  or  even  the  absence  of  one  or  more  of  these 
bodies.  Similar  changes  are  often  observed  in  the  cerebellum,  and 
occasionally  in  the  pons,  medulla  and  spinal  cord. 

Microscopically,  we  can  readily  detect  an  arrest  of  development  or 
disease  of  the  nerve  cells  of  the  brain  cortex,  of  the  nerve  fibers,  and 
of  the  neuroglia.  The  nerve  cells  are  immature,  irregularly  arranged 
or  numerically  deficient.  The  nerve  fibers  are  greatly  diminished  in 
number,  more  especially  in  the  frontal  and  parietal  lobes,  which  seem 
most  concerned  witli  the  highest  intellectual  functions.     The  neuroglia 

690 


AMENTIA  691 

is  quite  frequently  sclerosed  either  in  certain  portions  of  the  brain  or  in 
its  entirety. 

Sclerosis  and  porencephalia  usually  predominate  among  the  lesions 
encountered  in  the  different  varieties  of  amentia  of  infancy;  occasion- 
ally, however,  neoplasms,  especially  cysts,  and  local  softening  are 
detected  postmortem  in  cases  in  which  they  were  least  suspected  dur- 
ing life. 

The  cerebrospinal  fluid  is  either  increased  or  diminished  in  quan- 
tity, depending  chiefly  upon  the  size  of  the  skull  and  the  amount  of 
brain  structure  within  it. 

In  addition  to  the  diverse  pathologic  alterations  in  the  central  nerv- 
ous system,  postmortem  examination  of  mental  defectives  invariably 
discloses  also  several  lesions  in  other  parts  of  the  body.  The  ductless 
glands,  more  particularly,  the  thyroid,  thymus,  pituitary  and  adrenals 
are  often  in  a  state  of  rudimentary  development,  hypertrophy,  or  de- 
generation. The  cranial  bones  are  either  unusually  thick  or  thin,  and 
the  diploe  is  diminished.  The  tubular  bones  are  thick  and  short  and 
often  deformed.  It  is  not  uncommon  to  find  congenital  anomalies  of 
the  heart  and  blood  vessels,  and  of  the  abdominal  organs,  as  also 
malformations  of  the  eyes,  ears,  palate,  fingers  and  toes.  Indeed,  these 
anomalies  are  so  prevalent,  that  they  are  generally  accepted  as  special 
"stigmata  of  degeneration"  {q.  v.),  and  of  great  diagnostic  importance. 

Contemporary  authorities  are  very  much  inclined  to  advance  hered- 
ity to  the  forefront  of  the  etiologic  factors  of  mental  degeneracy,  Tred- 
gold,  for  example,  going  so  far  as  to  claim  a  neuropathic  ancestry  in 
from  60  to  70  per  cent  of  the  cases  of  amentia.  While  his  estimate 
may  precisely  agree  with  the  histories  of  amentia  housed  in  asylums 
and  special  hospitals  for  idiots,  it  seems  to  me  that  these  percentages 
by  far  exceed  those  obtained  in  private  practice.  Statistics  in  this 
direction  in  order  to  be  correct  would  have  to  embrace  not  only  the 
personal  and  family  history  of  the  institutional  cases  (almost  inva- 
riably of  the  worst  stock  and  lowest  class  of  society,  and  whose  very 
life  and  environment  are  conducive  to  mental  degeneracy),  but  also 
of  the  even  larger  number  of  aments  who  are  quietly  kept  at  home, 
and  whose  mental  degeneracy  is  the  result  either  of  antenatal,  natal 
or  postnatal  traumatism  or  disease,  and  who  often  succumb  at  an 
early  age,  not  rarely  long  before  the  exact  state  of  their  mentality  has 
at  all  been  determined. 

Those  who  claim  the  preponderance  of  a  tainted  heredity  as  the 
primary  cause  of  menal  deficiency  a  priori  concur  with  the  views  of 
Darwin  an4  his  disciples  who  hold  that  the  offspring  inherit  the  essen- 
tial characteristics  of  their  ancestors.    Now,  while  this  doctrine  unques- 


692  DISEASES    OF    CHILDREN 

tionably  applies  to  the  animal  species  as  a  whole  and  to  the  transmission 
of  normal  racial  characteristics,  I  very  mncli  doubt  if  it  conforms  to  the 
phenomena  of  disease,  which,  in  contrast  to  normal  attributes  of  the 
human  species,  form  ahnormal,  unnatural,  nay,  often  merely  accidental 
accessions. 

In  order  to  obtain  a  clear  conception  of  the  workings  of  heredity, 
I  think  it  best  to  assume  two  distinct  phases  thereof — namely,  one 
permanent,  which  has  become  fixed  during  the  long  course  of  evolu- 
tion; the  other,  temporary,  accidental  or  transient.  To  the  first, 
permanent ,  category  belongs  the  phenomenon  or  hereditary  transmission 
of  normal  racial  characteristics.  Taking  the  African  negro,  for  exam- 
ple, we  find  that  irrespective  of  the  laws  of  variation  and  mutation,  his 
offspring  always  maintain  their  racial  characteristics,  so  long  as  the 
negro  mates  with  members  of  his  own  clan.  And  even  were  he  per- 
sistently to  intermarry  with  descendants  of  the  white  race,  there  still 
would  be  little  likelihood  of  his  offspring  ever  entirely  overcoming  the 
attributes  of  their  African  ancestry.  It  certainly  would  require  a 
great  many  generations  to  swamp  the  negro  individuality,  w^ere  it  at 
all  conceivable  that  the  law  of  reversion  would  cease  its  vigilance  and 
tolerate  such  an  unnatural  process  of  evolution.  This,  then,  repre- 
sents the  permanent  phase  of  heredity.  The  second,  temporary,  prin- 
ciple of  heredity  here  suggested  is  strikingly  illustrated  by  the 
transiency  of  certain  bodily  physical  anomalies,  as  for  example,  super- 
numerary fingers  and  toes.  These  malformations  are  occasionally  ob- 
served in  several  members  of  one  family.  But  we  usually  note,  that 
just  as  soon  as  these  affected  individuals  intermarry  with  normally 
developed  individuals,  the  aforementioned  structural  anomalies,  with 
but  very  few  exceptions,  promptly  disappear  in  their  succeeding  genera- 
tions, for  the  very  good  reason  that  supernumerary  fingers  and  toes 
are  useless,  abnormal  and  unnatural  acquisitions,  and  hence  are 
dropped  by  nature  at  the  earliest  opportunity.  This  phase  of  tem- 
porary heredity  applies  with  equal  force  to  anomalies  of  development 
of  the  central  nervous  system.  Indeed,  so  anxious  is  nature  to  elimi- 
nate anomalies  of  development,  be  they  physical  or  mental,  that  the 
great  majority  of  degenerates  are  destroyed  in  the  germinal,  embryonic, 
fetal,  or  early  postnatal  stages  of  life,  or  if  they  happen  to  survive, 
are  usually  rendered  sterile,  in  order  to  prevent  the  procreation  of 
their  kind. 

With  these  considerations  in  view,  I  cannot  help  but  hesitate  to  be- 
lieve that  heredity  really  plays  so  important  a  role  in  the  propagation 
of  mental  deficiencies  as  is  generally  supposed,  and  am  inclined  to 
place  much  more  responsibility  upon  acquired  etiologic  factors.     This 


AMENTIA  693 

reasoning  is  partly  corroborated  by  the  investigations  of  Scholomo- 
Avitch,  Keller  and  Diem  Avho  found  that  the  difference  in  the  degener- 
acy ratio  among  the  offspring  of  sane  and  insane  ancestry  is  only 
about  10  per  cent  in  favor  of  the  former. 

The  fact  frequently  cited  that  on  rare  occasions  (c.  g.,  the  famous, 
or  rather  notorious  Jukes  family)  we  do  meet  hereditary  mental  de- 
generacy in  several  generations,  does  not  in  the  least  controvert  the 
here  proposed  modification  of  Darwin's  theory.  In  fact,  in  a  way  it 
even  confirms  it,  since  it  can  readily  be  shown  that,  as  a  rule,  mental 
degenerates  persistently  mate  with  individuals  of  similar  mental  caliber 
(for  anyone  with  sound  mind  could  hardly  be  induced  to  mate  with  an 
idiot!),  and  therefore  the  continuity  of  intermarriage  among  defectives 
generates  the  phase  of  permanent  heredity  previously  spoken  of ;  in  other 
words,  a  new  race,  as  it  were,  with  mentally  deficient  characteristics,  is 
created  which  does  for  some  time  and  would  forever  transmit  its  de- 
generacy to  its  offspring,  were  it  not  exterminated  by  nature  in  accord- 
ance with  the  law  of  natural  selection  and  destruction  of  the  unfit. 

The  modus  operandi  of  hereditary  transmission  is  still  veiled  in  deep 
mystery.  It  is  generally  assumed  that  in  mental  degenerates  the  germ 
plasm  of  the  male  or  female,  or  of  both,  is  defective  either  in  the  num- 
ber of  its  component  cells,  in  their  strength,  or  shape,  and  in  consequence 
fails  to  form  the  impetus  essential  to  normal  development  of  the  brain. 
It  is  further  postulated  that  under  certain  as  yet  mysterious  conditions 
the  germ  cells  of  the  opposite  sexes,  at  the  time  of  their  fusion,  are 
capable  to  influence  each  other,  either  for  good  or  bad,  in  accordance 
with  the  laws  of  natural  selection.  In  all  probability  a  tainted  germ 
plasm  is  deficient  in  more  than  one  of  its  elements,  since  the  degenerate 
brings  into  the  world  not  only  a  deteriorated  brain  but  quite  frequently 
also  several  anomalies  of  other  parts  of  the  body,  e.  g.,  abnormal  heart, 
extremities,  etc.  Furthermore,  there  is  ample  reason  for  the  belief  that 
the  anteconceptional  deficiencies  in  the  germ  plasm  which  are  produc- 
tive of  amentia  in  the  child  may  be  the  result  not  only  of  neuropathy  in 
the  parents,  but  also  of  other  pathologic  states,  more  especially  tuber- 
culosis, cancer,  syphilis,  and  the  like,  the  toxins  of  which  act  as  poison- 
ing and  deteriorating  agents  upon  the  germ  cells,  the  embyro  and  fetus, 
and  arrest  their  normal  development.  Statistics  are  greatly  at  variance 
as  to  the  exact  number  of  the  feebleminded  children  procreated  by  par- 
ents thus  afflicted.  The  family  histories  obtained  are  almost  always 
inaccurate,  since  but  very  few  parents  are  willing  to  admit  or  are 
aware  of*  the  prevalence  of  latent  tuberculosis,  syphilis,  etc.  amongst 
them.    Moreover,  it  is  only  with  the  evolution  of  the  Wassermann  and 


694  DISEASES    OF    CHILDREN 

tuberculin  reactions  that  the  statistics  pertaining  to  the  causes  of 
feeblemindedness  have  at  all  become  reliable. 

All  observers  agree  that  parental  alcoholism  forms  a  most  potent 
predisposing  cause  of  mental  degeneracy  in  the  offspring.  In  1901  the 
New  York  Academy  of  Medicine  undertook  a  careful  investigation 
of  the  effect  of  parental  intemperance  upon  their  children.  The 
family  history  of  3,711  school  children  through  three  generations 
was  traced  with  considerable  detail,  and  it  was  found  that  the  chil- 
dren of  temperate  parents  exceeded  in  proficiency  those  of  heavy 
drinkers  by  about  70  per  cent,  and  that  a  large  number  of  the  en- 
cumbered children  were  mentally  deficient  to  a  very  high  degree. 

The  etiologic  relation  of  consanguinity  to  amentia  is  still  subject 
to  controversy.  It  undoubtedly  greatly  depends  upon  the  physical 
and  mental  condition  of  the  individuals  concerned.  However,  it  has 
often  been  observed  that  all  hereditary  predispositions  to  disease  in 
the  parents  are  markedly  intensified  in  the  offspring.  Deaf-mutism 
is  particularly  prone  to  occur  as  a  result  of  union  of  near  relatives. 

The  postconceptional  causes  of  mental  deficiency  acting  upon  the 
embryo  and  fetus  are  as  prolific  as,  and  possibly  more  so  than,  those 
exerting  their  influence  through  heredity.  Notwithstanding  the  purity 
and  the  normal  activity  of  the  parental  germ  plasm,  it  may  yet  fail  in 
its  destiny,  if  the  soil  in  which  the  seed  is  to  grow  is  lacking  in  the  es- 
sential prerequisites  for  healthy  growth  and  development.  Let  me 
briefly  enumerate  the  various  intrauterine  morbid  conditions  which 
tend  to  disturb  the  normal  progress  of  the  embryo  or  fetus — in  one 
case,  e.  g.,  acting  harmfully  upon  the  extremities  or  heart;  in  another, 
upon  the  central  nerve  system : 

1.  Disease  of  the  uterine  tissues  surrounding  the  impregnated  ovum 
preventing  uniform  contact  between  the  maternal  and  embryonic  struc- 
tures and  facile  absorption  of  nutriment. 

2.  Internal  or  external  violence  acting  either  directly  or  indirectly 
upon  the  fetus. 

3.  Intra-  or  extrauterine  excessive  pressure  hampering  the  commodious 
and  equable  expansion  of  the  rapidly  growing  fetus. 

4.  High  degrees  of  toxemia  from  febrile  affections  or  poisoning  from 
slow  morbid  metabolic  processes,  e.  g.,  typhoid,  tuberculosis,  and  dia- 
betes, especially  during  the  early  period  of  pregnancy,  may  greatly 
affect  the  fetus,  and  finally, 

5.  Serious  domestic  trouble,  grave  mental  anxiety  and  extreme 
fright  with  prolonged  agitation  during  the  early  stages  of  pregnancy 
may  so  undermine  the  general  health  of  the  mother  as  to  disturb  in- 
directly the  normal  processes  of  growth  and  mental  development. 


AMENTIA  695 

111  this  connection  it  is  not  amiss  to  emphasize  also  that  many  of  the 
dystrophies,  especially  of  the  brain,  not  rarely  observed  in  prematurely 
born  infants,  are  the  direct  or  indirect  result  of  some  microscopic  or 
j?ross  pathologic  changes  either  in  the  thyroid,  parathyroids,  thymus, 
adrenals  or  the  hypophysis  originating  at  an  early  period  of  intrauter- 
ine life. 

There  still  remains  another  large  group  of  mentally  deficient  infants 
who  though  apparently'  normal  until  birth,  show  definite  manifestations 
of  amentia  some  time  thereafter.  Traumatism  during  delivery  has 
always  been  recognized  as  a  highly  potent  factor  in  the  production  of 
idiocy  and  the  allied  mental  deficiencies,  the  statistics  relative  to  these 
cases  ranging  anywhere  between  15  and  30  per  cent.  Where  the  cranial 
bones  are  fully  developed  and  the  maternal  pelvis  is  free  from  extreme 
contraction  or  deformity,  it  is  doubtful  whether  tedious  labor  per  se 
is  responsible  for  mental  deficiency  developing  during  early  childhood. 
On  the  other  hand,  forcible  instrumental  delivery  of  a  soft  skull  im- 
pacted in  a  narrow  rickety  pelvis  is  bound  to  effect  some  injury  to  the 
brain  and  leave  behind  a  permanent  mental  deficiency  in  the  child, 
more  especially  if  the  parietal  and  frontal  lobes  sustain  the  brunt 
of  the  injury.  Occasionally  severe  asphyxia  neonatorum  is  traceable  as 
an  immediate  cause  of  amentia,  undoubtedly  owing  to  suggillation  of 
and  quite  severe  hemorrhage  in  the  meninges  and  even  in  the  brain  that 
often  accompany  prolonged  asphyxia.  Amentia,  following  natal  trau- 
matism, not  rarely  makes  its  appearance  several  months  or  years  after 
the  injury  has  been  received,  and  is  often  preceded  by  epileptic  con- 
vulsions which  are  attributed  to  all  sorts  of  immaterial  causes.  Trau- 
matism in  early  infancy  is  an  especially  frequent  cause  of  mental  de- 
generacy in  children  of  the  slums,  whose  parents,  either  for  want  of 
means  or  of  good  sense  are  very  apt  to  leave  their  small  children  to  shift 
for  themselves,  so  that  knocks,  falls  and  bruises  form  part  and  parcel 
of  the  miserable  lot  of  their  unfortunate  babies.  Apparently  "the  Lord 
takes  care  of  the  helpless  children,"  for  Avere  it  otherwise  the  hordes  of 
idiots  would  have  swelled  beyond  calculation  or  imagination. 

Febrile  affections,  more  particularly  meningitis,  encephalitis  and 
exanthemata  form  very  material  etiologic  factors  of  permanent  de- 
generation of  the  infantile  central  nervous  system.  Acquired  hydro- 
cephalus supervening  upon  grave  gastroenteric  intoxication,  severe  at- 
tacks of  pertussis  (by  inducing  cerebral  hyperemia  or  local  hemorrhage), 
and  acquired  diseases  of  the  thyroid  (e.  g.,  endemic  cretinism)  most  prob- 
ably stand  next  in  frequency  as  etiologic  factors  of  amentia.  Not  rarely 
also  mental  backwardness  is  traceable  to  deprivation  of  senses,  such  as 
vision  and  hearing,  particularly  if  these  unfortunate  children  are  not 


696  DISEASES   OF    CHILDREN 

given  the  benefit  of  expert  treatment  and  training.  Several  authors 
mention  malnutrition,  rachitis  and  adenoids  as  rampant  causes  of  men- 
tal deficiency  in  young  children.  The  mental  dulncss,  liowever,  in  these 
cases  is  only  temporary,  promptly  giving  way  to  full  vigor  upon  re- 
moval of  underlying,  mentally  retarding,  factors. 

Diag"nosis. — After  reviewing  the  aforementioned  intricate  causes  of 
amentia,  we  can  readily  appreciate  the  importance  of  obtaining  a  clear 
personal  and  family  history  of  the  case  in  question.  It  is  especially 
essential  to  learn  whether  the  amentia  is  congenital  or  acquired,  since 
it  furnishes  the  most  reliable  clue  to  the  prognosis  and  treatment  of  the 
case.  In  taking  the  history,  however,  it  is  almost  equally  important  to 
remember  that  histories  obtained  from  parents  are  not  always  re- 
liable, first,  because  the  latter  are  rarely  very  certain  of  their  own 
mental  shortcomings,  and  more  especially  of  those  of  their  ancestors ; 
secondly,  they  are  usually  loath  to  admit  degeneracy  in  their  immediate 
family;  and  thirdly,  either  for  want  of  good  judgment,  or  in  the  hope 
of  favorably  influencing  the  doctor's  opinion,  they  are  very  apt  to  con- 
ceal certain  mental  inferiorities  of  their  infants  or  to  exaggerate  their 
mental  powers  and  thus  to  mislead  the  examiner.  However,  unreliable 
as  the  history  may  be,  it  always  furnishes  at  least  a  few  threads  of  in- 
formation which  help  to  direct  our  attention  to  some  mute  points  in  the 
diagnosis,  which  otherwise  would  escape  our  observation. 

The  taking  of  the  family  history  should  include  questions  as  to  in- 
sanity, idiocy,  dipsomania,  syphilis,  tuberculosis,  cancer,  epilepsy  and 
monstrosity  in  the  immediate  family,  both  on  the  father's  and  mother's 
side.  The  condition  of  the  previously  born  children,  if  any,  at  the  time 
of  birth  and  thereafter.  Diseases  of  the  mother  immediately  before  and 
during  pregnancy.  The  mental  state  of  the  mother  during  pregnancy, 
especially  as  regards  grief,  fright  or  extreme  emotion  from  other  causes. 
Traumatism  during  pregnancy,  possible  means  used  to  abort,  drug 
habits,  etc. 

The  past  and  immediate  history  of  the  patient  should  furnish  us  all 
details  as  regards  asphyxia,  bleeding  from  nose  and  mouth  and  injuries 
during  labor.  Appearance  of  the  head  and  other  portions  of  the  body 
immediately  after  birth.  Convulsions  at  this  time  or  at  any  time  there- 
after. Mode  of  feeding  and  physical  progress  of  the  child.  Diseases 
it  suffered  from,  particularly  as  to  exanthemata,  pertussis  and  otitis. 
Traumatism  and  its  immediate  consequences.  The  period  at  which  the 
infant  was  able  to  hold  its  head  erect,  to  sit  up,  to  stand  and  to  walk, 
when  the  teeth  made  their  appearance ;  and  also  the  age  of  the  baby  when 
it  made  the  first  attempt  to  speak.  It  is  also  advisable  to  let  the  mother 
relate  in  her  own  way  what  she  observed  of  the  mental  acumen  of  her 


AMENTIA  697 

child,  more  especially  in  reference  to  its  progressive  or  regressive  char- 
acter. This  is  important,  as  we  intend  to  show  later  that  some  idiots, 
e.  g.,  cretins  and  amaurotics,  get  more  stupid  as  they  grow  older. 

Lest  we  forget,  let  me  state  right  now  that  while  the  parents  are  busy 
relating  their  "experiences"  and  responding  to  questions,  and  the  pa- 
tient is  still  in  a  passive  mood  unmolested  and  unaroused  by  the  ordeal 
of  the  physical  and  mental  examination,  the  physician  should  avail  him- 
self of  the  opportunity  to  note  the  attitude  and  behavior  of  both  the 
parent  and  the  child  and  "to  size  up"  the  general  aspect  of  the  case. 
Indeed,  as  with  increased  experience  we  gradually  learn  to  see  aright, 
it  is  often  surprising  how  easily  we  can  arrive  at  a  correct  diagnosis  by 
mere  superficial  observation  of  the  patient.  This  statement  is  not  in- 
tended to  convey  the  idea  that  such  momentary  examination  should 
suffice  to  express  a  positive  diagnosis.  Quite  the  contrary ;  irrespective 
of  what  impression  we  gain  at  a  glance,  we  must  never  omit  a  very  care- 
ful and  minute  physical  examination  of  the  child  and*  this  completed, 
to  apply  all  the  mental  tests  presently  to  be  outlined.  But  I  do  desire  to 
lay  special  stress  upon  the  importance  of  training  ourselves  to  see  a 
great  many  things  at  a  glance.  After  undressing  the  child  we  proceed 
with  the  usual  physical  examination  of  children,  but  devote  a  little 
more  attention  to  inspection  and  mensuration  (see  p.  173)  which  enables 
us  to  reveal  the  pathognomonic  signs  of  amentia  and  more  particularly 
the  stigmata  of  degeneration  which  are  invaluable  in  the  differential 
diagnosis  between  congenital  and  acquired  amentia,  and  should  inva- 
riably receive  careful  consideration.  Therefore  let  us  briefly  enumerate 
them. 

Stigmata  of  Degeneration 

1.  Abnormalities  in  the  size  and  shape  of  the  head.  Softness  or 
bossing  of  the  cranial  bones.  Marked  gaping  or  premature  closure  of 
the  fontanelles  and  sutures.  Undue  distention  or  sinking  of  the  fon- 
tanelles. 

2.  Malformations  of  the  ears.  Irregularity  in  size.  Undue  promi- 
nence or  flattening.  Misshaped  helix,  antihelix,  tragus,  antitragus  and 
lobule.    Supernumerary  auricles,  auricular  appendages  or  atresia  auris. 

3.  Anomalies  of  the  eyes  or  lids.  Drooping  of  one  or  both  eyelids. 
Epicanthus  and  palpebral  fissures.  Congenital  cataract,  coloboma  iridis 
or  irideremia.     Micro-  or  anophthalmus.     Strabismus,  and  nystagmus. 

4.  Malformations  of  the  nose.  Saddle-shaped,  exceptionally  small 
and  broad,<  or  unduly  large  and  prominent.  Partial  or  complete  atresia 
of  the  posterior  nares. 


698  DISEASES    OF    CHILDREN 

5.  Malformations  of  the  face.  Undue  prominence  of  the  clieek  bones 
with  markedly  retracted  small  chin.  Clefts  of  face  and  lips.  V-shaped 
or  high  vaulted  palate.  Enlarged  protruding  and  often  cracked  tongue. 
Irregularly  shaped  and  implanted  teeth,  deficiency  or  excess  in  their 
number.  Inability  to  bring  jaws  closely  together  owing  to  irregularity 
of  dental  arches,  hence  constant  dribbling  of  saliva  from  half  open 
mouth. 

6.  Malformations  of  long  bones.  Curvatures  of  the  bones  of  the 
upper  and  lower  extremities.  Supernumerary  fingers  and  toes  or  de- 
ficiency in  their  number.  Syndactylism  or  fan-shaped  distribution. 
Disproportion  in  size  of  legs  and  arms.  Talipes,  spina  bifida,  and  caudal 
formations. 

7.  Umbilical  hernia :  diastasis  recti  abdominis.  Anomalies  of  the 
genitalia ;  epi-  and  hypospadias.  Malformations  of  the  rectum  and 
anus. 

Valuable  as  a  tainted  history  and  the  existence  of  stigmata  of  degen- 
eration are  as  diagnostic  aids  in  amentia ;  they  are  at  best  only  of  rela- 
tive value  in  estimating  the  mental  state  of  the  child  in  question.  It 
is  not  at  all  unusual  to  meet  with  perfectly  normal  children  who  present 
a  neuropathic  history  and  several  bodily  malformations,  and  vice  versa. 
Furthermore,  infants  of  certain  Mongolian  races  naturally  possess  the 
typical  Mongolian  facies  and  yet  may  be  fully  as  intelligent  as,  and 
possibly  more  so  than,  a  child  of  the  purest  white  race  with  an  un- 
blemished history  and  anatomy.  Hence,  before  declaring  an  infant 
mentally  deficient,  it  is  absolutely  indispensable  to  put  it  through  defi- 
nite physical  and  mental  tests,  which  reveal  the  mentality  of  children  of 
certain  ages  and  permit  not  only  the  distinction  between  the  normal 
and  abnormal  mentality,  but  the  degree  of  mental  deficiency  as  well. 
The  importance  of  such  an  examination  becomes  especially  evident  when 
we  bear  in  mind  the  fact  that  some  infants  are  merely  slow  in  their 
mental  development  as  a  result  of  diseases  or  faulty  environment,  but 
promptly  unfold  their  mental  powers  under  proper  care  and  treatment. 

In  order  to  be  able  to  estimate  the  mentality  of  an  infant  correctly, 
we  must,  of  course,  have  a  perfectly  clear  conception  of  the  normal  in- 
telligence at  different  periods  of  its  existence.  We  shall,  therefore, 
endeavor  to  depict  the  normal  mentality  of  the  infant  before  attempting 
to  outline  the  mental  tests  for  one  who  is  less  gifted. 

Normal  Intelligence 

According  to  the  latest  investigation,  a  normal  baby  can  hear  and  see 
immediately  after  birth.  He  feels  pain  when  he  is  hurt  and  cries  when 
he  is  uncomfortable  or  hungry,  and  exercises  his  extremities  and  the 


AMENTIA  699 

musculature  of  other  portions  of  the  body, — if  not  immobilized  by  an 
overabundance  of  coverings,  or  fancy  frocks  and  frills  and  bows  and 
strings. 

At  one  month  he  begins  to  locate  the  direction  of  sound  and  momen- 
tarily to  follow  a  bright  light. 

At  two  months  he  responds  to  snapping  of  the  fingers,  follows  bright 
objects  more  or  less  intently,  and  rejects  ill-tasting  food  or  drugs. 

At  three  months  he  holds  his  head  erect,  and  can  turn  it  steadily 
from  side  to  side ;  he  smiles  when  accosted,  shows  an  inclination  to  grasp 
bright  objects  displayed  in  front  of  him,  and  coos  when  in  good  humor. 

At  four  months  he  begins  to  recognize  his  mother  or  nurse,  or  those 
who  fondle  him ;  manipulates  things  put  in  the  hand,  e.  g.,  a  rattle ; 
plays  with  his  fingers,  and  brings  everything  to  his  mouth. 

At  five  months  he  knows  his  mother,  nurse  or  father,  and  puts  out 
his  hands  to  be  taken  when  they  approach.  When  crying  from  hunger 
he  stops  promptly  as  the  food  is  brought  near,  and  opens  his  mouth — 
ready  for  the  prey. 

At  six  months  he  is  interested  in  his  surroundings ;  sits  up  in  a  chair 
with  slight  support ;  shows  gratification  when  taken  outdoors. 

At  seven  months  he  recognizes  familiar  faces  from  a  distance ;  grasps 
after  objects  placed  at  a  short  distance;  begins  to  imitate  sounds  and 
syllables;*  laughs  aloud,  and  smiles  to  everybody,  and  cries  when 
scolded. 

At  eight  months  he  attempts  to  stand  if  held  erect  or  to  creep  if 
placed  on  the  floor.  He  is  often  able  to  repeat  "mama"  or  "papa,"  to 
clap  hands,  to  shake  bye-bye  and  to  perform  similar  little  ' '  baby  tricks. ' ' 
He  understands  several  words  spoken  to  and  enjoys  a  game  of  "peep 
bo"  and  the  like. 


*N.  J.  P.  Van  Bagg-en  (of  the  Hague,  Holland)  distinguishes  different  periods  in  the  de- 
velopment of  the  infant's  speech.  In  the  first  period  during  the  first  year,  the  infant  utters 
involuntary  sounds,  which  must  be  considered  as  a  simple  muscular  action  of  the  apparatus 
of  speech  produced  by  an  unconscious  reaction  of  the  numerous  stimuli  which  the  child  re- 
ceives from  without.  Later  on  the  stimuli,  becoming;  more  intense,  reach,  through  the  spinal 
marrow,  the  centers  of  the  cortex,  and  the  child  begins  to  feel  the  muscular  movements  and 
to  be  conscious  of  them.  About  the  same  time,  however,  the  child  begins  to  hear  the  sounds 
he  produces.  Henceforward  he  feels  those  sounds  as  well  as  he  hears  them.  Both  sensations 
now  leave  their  traces  on  the  cortex  of  the  brain  in  those  parts  which  are  destined  for 
the  motor  center  of  the  muscles  of  articulation  and  for  the  center  of  hearing.  The  sensation 
of  feeling,  and  that  of  hearing  the  word,  occur  simultaneously  and  therefore  they  become 
united  by  simultaneous  association.  The  child  now  begins  to  imitate  the  sound  he  produces 
himself  and  soon  thereafter  he  notices  the  sounds  produced  by  others  and  he  tries  to  imitate 
them. 

The  child  now  commences  to  appreciate  the  conformity  between  the  sounds  he  hears  and 
the  sounds  he  utters;  the  imitation  becomes  more  and  more  complete;  and  finally,  syllables  anu 
simple  words  are  pronounced.  However,  this  pronouncing  of  words  has  not  yet  any  meaning 
for  him.  It  is  only  gradually  that  the  association  between  the  heard  and  pronounced  word  anu 
the  realization  of  its  significance  takes  place.  This  association  is  brought  about  by  the  simul- 
taneous hearing  of  the  word  and  the  seeing  of  the  object  which  the  word  indicates.  Whenever 
the  child  sees  hi.s  doll,  the  word  doll  is  repeated  till  at  last  the  child  unites  the  word  doll 
inseparably  v^th  the  object  itself,  and  henceforward  the  heard  word  and  its  characteristic 
meaning  are  fixed  in  the  child's  memory.  The  child  enters  the  third  period  when  he  begins 
to  use  the  words  which  he  knows  by  memory.  When  he  wants  his  doll,  he  will  pronounce  the 
word  even  without  seeing  the  object  or  hearing  the  word  pronounced  by  standers-by. 


700  DISEASES    OP    CHILDREN 

At  nine  months  he  knows  his  name  and  also  turns  in  tlie  directions 
of  other  persons  who  are  accosted.  He  easily  holds  and  carries  his 
bottle  to  the  month ;  is  able  to  bite  off  and  masticate  solid  food.  If 
properly  trained,  he  indicates  his  desire  to  urinate  and  defecate. 

At  twelve  months  he  stands  alone,  or  by  holding  on  lightly  to  a  hand 
or  chair,  and  in  the  same  manner  attempts  also  to  walk.  lie  knows 
the  difference  between  the  articles  of  food  he  is  accustomed  to  eat.  He 
throws  a  kiss  or  actually  kisses. 

At  fifteen  months  he  makes  himself  thoroughly  understood  either  by 
signs  and  motions,  or  by  baby  language.  He  can  point  to  the  nose, 
eyes  and  ears,  etc.  He  is  interested  in  picture-books,  colors  and  differ- 
ent toys;  can  turn  pages  and  scribble  with  chalk  or  pencil.  He  knows 
the  difference  between  a  cat  and  a  dog,  and  is  often  able  to  name  them 
from  life  or  drawings.     He  can  play  a  toy  piano  or  mouth-harp. 

At  eighteen  months  he  usually  runs  about  freely  and  engages  in 
several  games,  such  as  throwing  balls,  marbles  and  the  like.  He  can 
imitate  all  sorts  of  performances,  such  as  dance,  jump,  hide,  rock  a 
doll,  etc.  He  knows  the  difference  between  right  and  wrong,  and  obeys 
or  rebels. 

At  two  years  he  knows  exactly  what  he  wants  in  the  way  of  food  or 
toys,  and  as  a  rule,  is  able  to  call  for  them.  He  speaks  with  character- 
istic gestures;  is  able  to  feed  himself,  and  to  distinguish  manifestations 
of  the  weather  (snow  or  rain). 

At  two  and  a  half  years  he  can  make  himself,  as  it  were,  useful 
around  the  house,  i.  e.,  do  little  errands.  He  begins  to  ask  questions  and 
to  "show  off."  He  recognizes  different  colors,  shows  constructive  abil- 
ity by  making  correct  use  of  building  blocks,  etc. ;  carries  simple  tunes 
and  memorizes  more  or  less  lengthy  nursery  rhymes. 

At  three  years  he  uses  the  personal  pronoun  in  conversation.  He 
shows  an  inclination  and  some  ability  to  dress  himself.  He  can  indicate 
the  seat  of  pain  or  annoyance.  If  instructed  he  can  count  up  to  ten,  at 
least,  and  spell  simple  words,  or  pick  several  letters  of  the  alphabet. 

The  physical  and  mental  activity  of  the  child  here  depicted  pertains 
of  course  to  that  of  average  normal  intelligence.  Some  infants  excel 
others  in  certain  capacities,  and  vice  versa.  It  is  not  at  all  uncommon, 
for  example,  for  some  babies  to  walk  and  to  talk  at  one  year  of  age,  or 
conversely,  barely  to  begin  either  at  two  years  or  even  later,  and  yet  be 
perfectly  normal  in  every  other  respect.  But  we  must  set  before  us  a 
standard  of  the  average  and  not  of  the  exceptional  baby,  and  with  due 
allowance  for  delay  of  development  as  a  result  of  disease  or  lack  of 
training,  compare  the  physical  and  mental  activity  of  the  baby  under 
examination  with  that  of  the  assumed  normal  standard. 


AMENTIA  A  r  f    r    ^  ^  701 

■  '  J  I-    I        -    I.-  r 

Judging  from  the  foregoing  discussion,  a  normal  infant  is  supposed 
to  acquire  the  power  of  seeing,  liearing,  taste  and  touch  wlien  he  reaches 
the  first  four  months  of  his  life ;  attention,  voluntary  motion  and  per- 
ception during  the  second  four  months;  imitation,  speech  and  under- 
standing in  the  third  four  months,  and  gradually,  from  month  to  month, 
to  unfold  and  to  strengthen  these  qualities,  so  that  at  the  age  of  about 
three  years  he  has  developed  into  a  real  human  being  intellectually. 
Let  us  now  attempt  to  analyze  those  qualities  as  they  are  manifested  in 
mentally  deficient  children  and  to  suggest  workable  mental  tests  to 
facilitate  their  early  recognition. 

THE  ABNORMAL  BABY 

Vision.- — As  a  rule  idiots  gaze  vaguely  into  empty  space  or  irregularly 
rotate  their  eyes  in  all  directions.  They  rarely  follow  a  bright  object 
placed  before  them  and  it  is  almost  impossible  to  fix  their  attention 
upon  one  point  for  more  than  a  few  moments.  In  testing  their  power 
of  vision,  however,  we  must  assure  ourselves  of  the  absence  of  congenital 
or  acquired  obstruction  to  vision,  e.  g.,  congenital  cataract,  large  staphy- 
lomas and  the  like.  Sollier  maintains  that  blindness  is  encountered  in 
from  7  to  8  per  cent  of  idiots.  The  importance  of  an  early  ophthal- 
moscopic examination  of  the  eyes  cannot  too  strongly  be  emphasized, 
since  by  this  means  only  are  we  able  to  detect  optic  atrophy,  symmetrical 
changes  in  the  macula,  and  choroid  tubercules,  which  are  often  decisive 
in  the  diagnosis  of  amentia  of  cerebral  origin. 

Hearing".- — The  sense  of  hearing  is  easily  tested  by  starting  some  sort 
of  a  noise  (ringing  of  a  bell,  clapping  of  the  hands)  while  the  patient 
is  unawares.  The  ament  who  hears  will  ordinarily  be  startled  by  the 
noise,  at  least  momentarily,  even  though  he  usually  fails  to  turn  in  the 
direction  of  the  noise.  Some  aments,  e.  g.,  amaurotics,  are  often  vio- 
lently startled  by  the  slightest  clapping  of  the  hands.  Deafness  in 
connection  with  amentia  is  a  rare  congenital  anomaly  and  almost  never 
forms  the  sole  cause  of  true  mental  deficiency.    (See  p.  730.) 

Sense  of  Taste  and  Smell. — One  of  the  very  earliest  signs  of  amentia 
is  obtuseness  or  perversion  of  the  sense  of  taste.  Aments  either  chew 
everything  put  in  their  mouths,  regardless  of  its  disgusting  taste,  or 
conversely,  spit  out  the  most  pleasant  delicacies,  because  of  their  in- 
ability to  detect  their  agreeable  taste.  They  relish  quinine  as  greedily 
as  sugar,  or  refuse  both.  This  perversion  of  taste  explains  why  some 
aments  are  gluttons  and  others  again  barely  eat  enough  to  sustain  life. 
The  sense, of  smell  is  equally  affected,  but  cannot  be  tested  with  any 
degree  of  exactitude  until  the  child  has  attained  considerable  intelli- 


■^ItJO^  h  lA^hQl  DISEASES   OF    CHILDREN 

^ence^    .Some  cli;nicians  record  lack  of  local  or  reflex  response  to  irri- 
^  ^ '-     tating  odors,  such  as  ammonia.     In  these  cases,  however,  we  are  most 
probably  dealing  with  malformations  of  the  nose    (e.  g.,   atresia),  so 
that  the  strong  odor  does  not  at  all  reach  the  olfactory  nerve. 

Sense  of  Touch,  Pain  and  Temperature. — Almost  all  confirmed  idiots 
are  insensitive  to  pain  and  temperature,  hence  are  frequently  seen 
burnt,  bruised  and  bitten  without  showing  any  signs  of  discomfort. 
Indeed,  some  of  them  delight  in  mutilating  themselves.  It  is  of  daily 
experience  to  find  a  mentally  deficient  child  squatting  on  the  floor,  bed 
or  chair,  rocking  to  and  fro,  diligently  cracking  his  fingers  or  biting 
his  hands,  often  until  they  bleed,  and  rebelling  and  howling  if  inter- 
rupted in  his  apparent  state  of  enjoyment.     So  characteristic  and  im- 


Fig.  206. — Microcephalic  idiot.     Status  Idioticus.     Fig.  207. — Amaurotic   idiot. 
(Peculiar  attitude  assumed  by  idiots  in  sitting  posture.) 

pressive  is  this  peculiar  attitude  of  the  ament  that  a  few  years  ago  I 
ventured  to  describe  it  as  the  "Status  Idioticus"  (Figs.  206  and  207). 
In  congenital  amentia  there  is  frequently  general  anesthesia,  while  in  ac- 
quired cases  the  anesthesia  is  not  rarely  localized  over  large  areas  of  the 
body,  more  especially  in  connection  with  paralysis.  Tactile  sense  is  not 
nearly  as  obtuse  as  that  of  temperature  or  pain,  in  fact,  some  aments,  like 
the  blind,  show  a  distinct  hyperacuity  of  tactile  sensibility,  being  able  by 
mere  touch  to  recognize  the  individuals  who  take  care  of  them. 

Attention. — No  other  defective  mental  action  so  readily  betrays  the 
mental  incapacity  of  an  infant  as  his  lack  of  power  of  attention.  As 
already  stated,  a  normal  infant   barely  three  months  old,   shows  his 


AMENTIA  703 

power  of  attention  by  turning  in  the  direction  of  the  sound  of  a  bell, 
for  instance,  and  watches  the  course  of  a  bright  object  slowly  passed  be- 
fore his  eyes.  The  ament  of  a  much  more  advanced  age,  on  the  other 
hand,  is  entireh^  unccncerned  about  what  is  happening  around  him.  He 
may  suddenly  start  when  frightened  by  a  flash  of  lightning  and  he  may 
be  aroused  from  his  lethargic  state  bj-  the  approach  of  one  who  takes  care 
of  him,  hut  lie  immediately  falls  back  into  his  callosity  just  as  soon  as 
the  artificial  agitation  has  subsided.  He  is  entirely  devoid  of  initiative 
and  spontaneity,  and  may  for  hours  sit  huddled  up  in  one  spot  as  long 
as  he  is  not  disturbed  from  sucking  his  thumbs. 

Perception. — This  utter  incapacity  of  attention,  of  course,  goes 
hand  in  hand  with  dulness  of  perception.  The  less  attention  the  ament 
pays  to  the  doings  and  actions  of  others,  the  fewer  are  the  impressions 
that  reach  his  brain,  and  the  less  capable  is  his  cerebrum  to  perceive  out- 
side impulses.  Moreover,  his  memory  is  so  flighty  that  he  is  unable  to 
treasure  up  for  future  use  the  impressions  he  receives.  Again  and 
again,  for  example,  will  idiots  suffer  pain  from  the  effects  of  burns  or 
other  injuries,  and  yet  when  exposed  to  the  same  or  similar  harmful 
forces,  they  will  not  at  all  attempt  to  guard  themselves  against  injury, 
for  the  very  reason  that  frcm  one  time  to  another  they  forget  what 
happened  to  them  under  such  circumstances.  They  rarely  recognize 
familiar  faces  and  cannot  differentiate  one  object  from  another  unless 
specially  trained  in  this  direction. 

Imitation. — In  view  of  faulty  memory,  attention  and  perception,  it 
is  hardly  to  be  expected  that  a  degenerate  of  this  sort  would  be  capa- 
ble of  imitation.  It  is  true,  some  of  them  do  perform  little  tricks 
affer  repeated  training,  more  especially  when  encouraged  by  mother 
or  nurse,  but  their  activity  is  extremely  limited,  and  their  perform- 
ance very  awkward.  Unlike  normal  infants  they  do  not  "show  off" 
spontaneously.  Very  often  after  learning  one  movement  they  keep 
on  repeating  the  same  almost  indefinitely,  or  until  they  have  managed 
to  learn  something  else  to  replace  it.  The  same  lack  of  pow'er  of 
imitation  hinders  them  from  engaging  in  any  kind  of  games,  and,  later 
in  life,  to  learn  to  read  or  write,  or  to  acquire  mechanical  skill  to 
practice  a  trade,  although,  exceptionally,  some  aments  do  show  con- 
sideralile  constructive  talent  and  ingenuity. 

Voluntary  Motion.— Profound  amentia  is  invariably  associated  with 
muscular  insufficiency  and  incoordination.  Not  only  are  mentally  de- 
ficient infants  lacking  in  initiative  to  grasp  objects  displayed  before 
them,  but  even  if  objects  are  placed  in  their  hands,  they  are  usually 
incapable  of  getting  a  firm  hold  of,  or  to  manipulate,  them.  As  a  rule, 
they  are  unable  to  measure  distance;  hence,  like  the  blind,  they  feel 


704  DISEASES   OF    CHILDREN 

their  way  in  different  directions,  if  they  ever  manifest  a  desire  to 
locate  a  certain  object.  Amentia  is  frequently  accompanied  by  paraly- 
sis of  the  extremities,  but  even  in  its  absence  aments  very  rarely  be- 
gin to  walk  before  two  or  three  years  of  age,  chiefly  because  they  are 
slow  to  learn  the  special  voluntary  movements  required  in  the  primary 
act  of  walking.  In  a  similar  manner  they  rarely  learn  to  feed  them- 
selves with  a  spoon ;  they  are  sure  to  spill  its  contents  before  bringing 
it  to  the  mouth.  Quite  a  number  of  aments  seem  to  experience  con- 
siderable difficulty  also  to  manipulate  the  tongue,  which  possibly  ex- 
plains their  frequent  inability  to  masticate  solid  articles  of  food. 

Speech. — Marked  delay  to  walk  as  well  as  to  talk  is  almost  pathog- 
nomonic of  amentia.  Occasionally,  a  mentally  deficient  infant  may 
succeed  in  repeating  a  few  single  short  words  at  an  early  age,  but  he  is 
never  able  to  pronounce  correctly  several  words  in  succession  so  as 
to  form  an  intelligible  sentence.  Some  aments,  as  they  get  older, 
keep  on  chattering  incoherently  and  without  measure,  but  they  are 
no  wiser  than  the  others  who  never  utter  a  single  syllable.  Hence  in 
judging  the  mental  capacity  of  the  idiot,  it  is  not  the  number  of  words 
he  can  pronounce  that  counts,  but  the  way  he  speaks  and  what  he 
says.  Aments  often  bring  out  the  words  in  staccato  fashion — slow, 
broken  or  "scanning,"  and  having,  as  a  rule,  an  imperfect  image  of 
words,  cannot  pick  the  right  words  for  the  particular  things  they 
desire,  and  therefore  fail  to  make  themselves  understood. 

Intelligence. — All  the  aforementioned  attributes  of  the  brain  col- 
lectively serve  to  nlould  the  human  intellect  as  a  whole.  But  an  in- 
fant may  be  able  to  see  and  to  hear,  smell  and  taste,  pay  attention, 
imitate,  perceive  outside  impressions  and,  finally,  to  walk  and  to  emit 
sounds,  and  yet  not  be  endowed  with  normal  human  intelligence. 
Practically  every  domestic  animal  possesses  these  faculties.  The 
human  mind  differs  from  that  of  the  lower  animal  by  its  acquired 
faculties  (not  instinct)  to  distinguish  right  from  wrong,  to  reason, 
judge,  associate  ideas,  and  to  act  spontaneously  from  previous  expe- 
rience. Now,  while  a  properly  trained  infant,  let  us  say  of  three 
years,  fully  appreciates  that  he  is  wrong  to  get  soiled,  reasons  how 
b&st  to  avoid  punishment,  e.  g.,  by  putting  the  blame  on  someone  else, 
associates  ideas,  by  looking  for  paper  when  you  hand  him  a  pencil ;  uses 
judgment,  by  not  attempting  to  cross  the  street  when  seeing  an  auto- 
mobile approaching,  and  finally,  shows  spontaneity  and  power  of  im- 
agination, by  making  use,  for  example,  of  a  box,  string  and  cane,  to  take 
the  place  of  a  horse,  whip  and  wagon,  the  mentally  deficient  child  is 
utterly  lacking  all  these  mental  capacities  and  performs  certain  ac- 
tions only  automatically  by  imitation  after  persistent  training.     Of 


AMENTIA  705 

course,  not  all  ameiits  are  alike  in  their  mental  acumen.  We  nnist 
always  bear  in  mind  that  there  are  different  degrees  of  amentia,  just  as 
there  are  variously  gifted  normal  infants.  But  whereas  the  normal  child 
through  outside  influences  easily  and  readily  acquires  certain  mental 
qualities  as  he  gets  older  in  months  and  years  and  experience,  the 
abnormal  child,  owing  to  some  faulty  congenital  or  acquired  anomalies 
of  the  brain  is  unfolding  those  mental  powers  at  a  very  much  later 
age,  if  ever.  And  it  is  w-ith  the  object  in  view  to  determine  to  which 
period  of  life  the  mental  capacity  of  the  infant  under  examination — ■ 
as  compared  with  the  average  normal  child — corresponds,  that  we 
shall  presently  endeavor  to  outline  helpful  mental  tests  for  our  guid- 
ance. 

Mental  Tests* 

Mental  Age,  Six  Months. — Move  bright  object  in  front  of  the  child ; 
note  if  he  follow^s  it.  Ring  bell  at  a  distance  of  about  2  feet  from  the 
baby ;  note  if  he  turns  around. 

Prick  the  baby's  skin  lightly  with  the  point  of  a  needle;  watch  for 
prompt  facial  expression  of  annoyance. 

While  the  baby  drinks  his  milk  mixture,  remove  the  bottle  from  his 
mouth  and  substitute  a  bottle  containing  a  trace  "of  quinine,  salt  or 
nux  vomica,  or  warm  water.  Note  how  he  takes  any  of  the  solutions. 
The  normal  baby  shows  the  possession  of  the  'sense  of  taste  by 
promptly  refusing  even  the  plain  Avater. 

Hold  the  baby's  food  at  a  short  distance;  watch. the  baby's  facial 
expression  of  satisfaction  and  desire  to  grasp  the  bottle  or  breast. 
Let  the  mother  leave  the  room  and  return  from  another  direction ; 
note  promptness  of  attention. 

Put  the  baby  on  the  mother's  lap  and  note  his  power  to  hold  his 
head  erect  and  to  sit  up  with  but  slight  support. 

Mental  Age,  Twelve  Months. — While  unawares,  call  infant  from  a 
distance;  note  if  he  turns  in  the  direction  of  the  voice. 

Put  a  colored  object  in  the  baby's  hand,  then  place  in  front  of  him 
some  article  of  food  the  baby  is  especially  fond  of ;  note  if  he  drops 
the  toy  and  reaches  out  for  the  food. 

Let  the  mother  encourage  her  baby  to  clap  hands,  shake  "bye-bye" 
and  perform  similar  "baby  tricks";  note  its  power  of  imitation. 

Mental  Age,  Eighteen  Months. — Engage  the  baby  in  simple  games, 
such  as  throwing  ball  and  the  like ;  note  his  dexterity. 


*In  infants  6{  a  year  or  elder  it  is  preferable  to   let  the  mother  apply   the  mental  tests,   lest 
the  child   be  unduly  disturbed  by  a  stranger. 


706  DISEASES   OF    CHILDREN 

Hand  the  baby  a  pencil  and  some  article  of  food ;  note  liis  under- 
standing of  their  use. 

Let  the  mother  encourage  the  baby  to  repeat  "papa,"  "mama"  or 
similar  words;  note  his  power  of  articulation  of  syllables  and  words. 

Mental  Age,  Two  Years.- — Learn  whether  the  baby  knows  his  own 
name  and  that  of  his  mother,  brother  or  any  other  member  of  the 
family. 

Hand  the  baby  some  article  of  food;  note  his  power  to  bite  and  mas- 
ticate. 

Put  in  front  of  the  baby  some  constructive  toy ;  note  its  power  to 
manipulate  the  same,  e.  g.,  to  "build  a  house"  of  wooden  blocks. 

Ask  the  baby  to  point  to  his  nose,  mouth,  eyes,  etc.;  note  promptness 
of  response. 

Mental  Age,  Three  Years. — Encourage  baby  to  repeat  several  num- 
bers or  short  nursery  rhymes  he  was  taught  to  recite,  or  to  sing;  note 
his  power  to  memorize. 

Place  the  child  in  front  of  a  window  and  let  him  tell  you  what  he 
sees  on  the  street ;  note  his  ability  to  distinguish  men  from  animals  or 
objects. 

Show  him  a  picture-book  with  different  animals  and  ask  him  to 
point  to  a  horse,  cat,  bird,  etc. ;  note  the  ease  of  response. 

Display  several  pictures  of  relatives  and  let  him  pick  those  of  par- 
ents. 

Direct  him  to  bring  you  different  small  objects  from  the  bureau 
drawers  or  closets:  note  his  way  of  going  about  it  and  the  ease  with 
which  he  locates  them. 

If  already  instructed,  ask  him  to  spell  his  name,  to  count,  etc. ;  note 
his  memorizing  power. 

Mental  Age,  Four  Years. — Test  his  ability  to  feed  himself  with 
spoon  or  fork. 

Let  him  reply  to  the  following  questions:  Where  do  you  live? 
Where  do  you  sleep?  What  did  you  have  for  luncheon  today,  or, 
possibly,  yesterday?  How  old  are  you?  Almost  all  normal  children 
of  four  years  are  able  to  respond  promptly  to  these  questions,  or  to 
similar  ones. 

Let  him  pick  out  several  letters  of  the  alphabet,  especially  those 
required  to  spell  his  name ;  note  the  ease  with  which  he  accomplishes 
it.  He  is  usually  able  to  do  it,  if  previously  entertained  with  toy 
alphabets. 

Classification 

In  addition  to  these  simple  tests  which  serve  to  establish  the  diag- 
nosis of  amentia  in  general,  we  have  a  number  of  pathognomonic  clin- 


AMENTIA 


707 


ical  syndromes  which  in  view  of  their  usual  occurrence  with  certain 
lesions  in  the  brain  and  ductless  glands,  enable  us  to  classify  amentia 
in  the  following  distinct  clinical  groups :  Amentia  symptomatic  of 
microcephalus,  hydrocephalus  and  cerebral  hemorrhage  and  inflam- 
mation; amaurotic  family  idiocy;  mongolism;  cretinism  or  myxidiocy, 
infantilism  and  mental  retardation  (moramentia)  from  otlier  causes  all 
of  which  will  presently  receive  full  consideration. 


Fig.  208. — Microceplialus — miniature  brain. 

Microcephalus 

From  a  large  number  of  cases  under  observation  I  have  been 
tempted  to  distinguish  two  forms  of  microcephalus.  One,  in  which 
the  brain  as  a  whole  is  very  miniature,  but  not  deficient  in  its  com- 
ponent parts,  thus  showing  arrest  of  development,  but  not  a  state  of 
disease.  Xhe  second  variety  is  characterized  by  an  absence  or  degen- 
eration of  several  components  of  the  brain,  such  as  the  peduncles. 


f08 


DISEASES   OF    CHILDREN 


pyramids  or  even  an  entire  liemispliere.  In  these  eases  tliere  may 
even  be  an  hydrocephalus  in  conjunction  witli  the  mieroeephalns.  In 
the  first  variety  of  mieroeephalns  (Fig.  208)  the  skull  is  thick,  very 
small  and  sometimes  deeply  furrowed.  The  cranial  sutures  are  ef- 
faced and  the  fontanelles  completely  ossified.  In  the  second  variety 
(Fig.  209)  the  reverse  may  be  the  case.  Indeed,  in  some  microcephalies 
the  skull  may  be  moderately  large  and  irregular  in  shape  (''dome" 
or  "sugar-loaf" — see  Fig.  206).  In  microcephalics  there  is  often  also 
a  hypoplasia  of  the  spinal  cord,  more  especially  of  the  pyramidal  tracts 
.-.nd  the  columns  of  Goll. 


Fig.   209. — Mieroeephalns — brain   degeneration. 

Where  the  brain  is  intact  but  miniature,  there  is  general  inactivity 
of  the  cerebrospinal  system.  The  child  is  entirely  helpless  during 
infancy,  but  occasionally^  gradually  improves  physically  as  he  gets 
older.  As  the  cranial  bones  are  completely  ossified,  and  the  immature 
brain  no  longer  has  the  facility  to  develop,  the  mental  faculties  of  the 
child  remain  permanently  in  an  infantile  state.  On  the  other  hand, 
in  the  second  variety  of  mieroeephalns  the  mental  and  physical  condi- 
tion of  the  child  depends  entirely  upon  the  pathologic  alterations  of 


AMENTIA  70!) 

the  ])rain.  Where  the  motor  area  is  involved,  we  have  disturbance 
of  locomotion,  convulsions,  athetosis,  rigidity  and  many  other  symp- 
toms that  usually  accompany  cerebral  lesions.  The  mental  state  of 
the  child  ranges  from  feeblemindedness  to  profound  idiocy.  As  these 
children  get  older,  they  are  usually  obstinate,  vulgar  and  very  irri- 
table. Some  of  them  understand  simple  words  addressed  to  them  and 
are  able  to  imitate  certain  actions  after  prolonged  training.  They 
may  learn  to  feed  themselves,  to  do  little  errands,  and  possibly  to 
help  in  some  trade  under  the  guidance  of  a  master.  The  majority  of 
them,  however,  are  entirely  devoid  of  understanding  and  take  no 
interest  in  their  surroundings;  and  especially  while  under  three  or 
four  years  of  age,  they  may  for  hours  sit  or  lie  in  one  position  and  in- 
dulge in  irregular  movements,  Avithout  by  attitude  or  facial  expres- 
sion indicating  any  desire  for  a  change  or  even  betraying  any  dis- 
comfort during  or  after  defecation  or  urination.  Owing  to  their  ex- 
treme restlessness  and  awkwardness  of  locomotion,  their  grotesque 
movements,  in  hopping  from  place  to  place,  often  resemble  those  of 
rabbits,  goats  or  monkeys,  and  in  times  bygone  they  were  exhibited 
by  showmen  as  curious  descendants  of  a  lost  degenerated  tribe.  Some 
of  them  are  witty  and  alert  and  show  distinct  powers  of  mimicry,  but 
they  never  attain  a  sufficiently  high  degree  of  intelligence  to  earn 
a  livelihood  independently. 

The  diagnosis  of  microcephalus  is  based  principally  upon  the  size 
and  shape  of  the  head.  In  the  first  variety  of  microcephalus,  where 
owing  to  early  arrest  of  development  of  the  brain  the  cranial  bones 
ossify  before  or  immediately  after  birth,  the  circumference  of  the 
skull  always  remains  from  3  to  6  inches  below  that  of  the  average 
normal  child.  To  a  slighter  extent  (2  to  3  inches)  this  is  true  also  of 
the  second  variety  of  microcephalus.  The  hair  is  often  so  coarse  and 
wiry  that  as  Tredgold  puts  it,  the  teeth  of  the  clippers  often  break 
whilst  the  hair  is  being  cut.  A  microcephalic  idiot  may  sometimes  be 
mistaken  for  a  Mongolian.  In  mongolism,  however,  the  head  is  not 
quite  as  small  or  malformed,  the  hair  not  as  coarse,  and  the  muscular 
flaccidity  or  rigidity  not  quite  as  pronounced,  while  in  microcephalus  pro- 
trusion and  cracking  of  the  tongue  is  exceptional.  In  early  infancy  the 
mentality  of  the  Mongolian  is  on  a  higher  plane  than  that  of  the  micro- 
cephalic idiot.  The  flaccid  type  of  microcephalus  may  occasionally  re- 
semble amaurotic  family  idiocy.  In  the  latter  condition,  however,  there 
is  usually  a  history  of  gradual  degeneration  after  birth ;  the  fontanelles 
are  usually  open,  the  size  and  shape  of  the  head  fairly  normal,  and  an 
ophthalmoscopic  examination  reveals  pathognomonic  changes  in  the 
retina  (q.  v.).    The  aforementioned  symptoms  of  microcephalus  are  also 


710 


DISEASES    OP    CHILDREN 


ample  to  differentiate  this  form  of  amentia  from  that  associated  with 
traumatic  cerebral  palsy.  Besides,  in  paralytic  amentia  of  natal  origin, 
congenital  stigmata  of  degeneration  (q.  v.)  which  almost  invariably  pre- 
vail in  microcephalus,  and  the  "idiotic  grunt" — the  gutteral  noise  which 
the  microcephalic  usually  exhibits  particularly  when  he  is  enjoying  a 
square  meal — are  usually  absent.  Finally,  it  is  well  to  bear  in  mind 
that  "sugar-loaf"  head  (oxycephaly)  is  occasionally  met  with  in  per- 
fectly normal  children. 

Hydrocephalus* 

The  pathologic  anatomy  in  hydrocephalic   amentia  varies   greatly 
with  the  quantity  of  cerebrospinal  fluid  in  the  cranial   cavity,   the 


Fig.  210. — Hydrocephalic  idiot. 


period  of  its  appearance  and  the  length  of  time  it  has  continued  to 
exert  pressure  upon  the  vital  structures  of  the  brain.  Thus  do  we 
find  that  in  cases  of  postnatal  hydrocephalus  where  the  pressure  hap- 
pens to  be  slight  and  temporary,  the  pathologic  alterations  in  the  brain 
are  often  insignificant,  w^hereas  in  marked  congenital  hydrocephalus 


'For   "Acquired,   Acute   and    Chronic    Hydrocei^halus,"    see   p.    596. 


AMENTIA  711 

postmortem  examination  usualh*  reveals  considerable  atrophy  of  sev- 
eral parts  of  the  brain.  The  brain  markings  are  generally  eiTaeed,  the 
ventricles  distended  and  their  contiguous  structures  compressed  and 
degenerated.  The  meninges  are  thin  and  bulging,  the  cranial  bones 
greatly  atrophied,  and  the  fontanelles  and  sutures  widely  gaping  with 
Wormian  bodies  freely  distributed  in  the  intervening  spaces.  Not 
rarely  hydrocephalus  is  associated  with  spina  bifida — undoubtedly 
Nature's  attempt  to  relieve  the  excessive  intracranial  pressure  (Fig. 
210). 

The  most  striking  physical  sign  of  hydrocephalic  amentia  is  the  ex- 
traordinary size  and  shape  of  the  head.  The  head  is  usually  asym- 
metrical, twisted  in  appearance  (plagioeephalic),  but  may  be  rounded, 
egg-shaped  (brachycephalic),  long  and  narrow  (dolichocephalic),  or 
keel-shaped  (scaphocephalic).  The  circumference  of  the  head  ranges 
between  22  and  30  inches  or  more.  The  scalp  is  very  thin  and  barely 
covered  by  fine  hair  and  traversed  by  conspicuous  veins.  The  cranial 
bones  are  soft  and  often  yield  to  light  pressure  with  the  finger,  im- 
parting the  sensation  of  parchment.  In  severe  cases  the  orbital  plates 
are  pushed  downwards  while  the  eyeballs  protrude  forward,  so  that 
the  lids  are  more  or  less  retracted,  leaving  a  ring  of  the  sclerotic  ex- 
posed. This  anomaly  gives  rise  to  the  peculiar  staring  expression  of 
the  eyes  which  is  characteristic  of  the  hydrocephalic  idiot,  and  is  es- 
pecially pronounced  when  accompanied  by  strabismus  and  nystagmus. 

The  mental  symptoms  are  not  invariably  correlated  to  the  size  of 
the  head,  some  infants  with  huge  heads  occasionally  possessing  more 
intelligence  than  those  with  proportionately  smaller  heads.  And  if, 
perchance,  the  hydrocephalus  is  arrested  before  permanent  damage  to 
the  brain  has  been  wrought,  the  hydrocephalic  may  yet  grow  up  with 
a  fair  degree  of  mental  capacity.  Ordinarily  hydrocephalic  aments 
are  quiet,  gentle,  timid,  sorroAvful  and  affectionate,  and  but  little  im- 
pressionable or  curious.  Owing  to  impaired  function  of  the  extremities 
by  paraplegia  and  spasmodic  contractures  of  the  arms,  they  are  rarely 
able  to  walk  about  and  to  help  themselves,  and  when,  as  is  often  the 
case,  vision  (optic  atrophy)  and  hearing  are  affected,  they  usually  re- 
main infantile  for  life — which  latter,  fortunately  is  very  rarely  of  long 
duration.  Occasionally,  hydrocephalus  is  associated  with  adipositas 
(Fig.  171),  which  most  probably  occurs  in  consequence  of  interference 
with  the  functional  activity  of  the  hypophysis  cerebri. 

Chronic  hydrocephalus  may  be  confounded  with  rachitis,  syphilis 
and  macrocephalus  in  connection  with  hypertrophy  of  the  brain.  In 
rachitis  th£  extremities  are  weak  but  neither  paralyzed  nor  rigid,  while 
mental  deficiency,  if  present,  is  but  slight;  in  hydrocephalic  amentia 


712  DISEASES   OF    CHILDREN 

the  reverse  is  the  ease.  Tlie  rickety  head  never  attains  the  size  of  that 
of  the  hydrocephalic,  and  the  cranial  bones  rapidly  assume  their  nor- 
mal consistency  upon  removal  of  the  cause  of  rickets,  i.  e.,  on  attention 
to  hygiene  and  proper  nutrition  and  administration  of  lime  and  phos- 
phorus. In  rachitis  we  usually  find  that  in  the  first  few  months  of  its 
existence  the  child's  physical  and  mental  condition  was  normal, 
whereas  in  hydrocephalus  there  is  a  history  of  the  presence  of  all  of 
the  aforementioned  symptoms  from  birth  on,  or  their  sudden  develop- 
ment in  connection  with  some  serious  acute  ai^ection,  especially  tuber- 
culous or  cerebrospinal  meningitis  (q.v.).  Moreover  in  these  cases 
the  child  rarely  escapes  severe  involvement  of  the  eyes  and  ears.  In 
syphilis  the  head  is  not  rarely  greatly  enlarged,  but  instead  of  being 
unusually  soft  it  is  often  hard  and  bossed.  Of  course,  where  the 
syphilitic  is  also  suifering  from  hydrocephalus,  which  is  not  at  all 
uncommon  (Fig.  137),  the  ditferential  diagnosis  between  these  two 
forms  of  amentia  can  be  made  only  by  means  of  Wassermann  reac- 
tion, which  should  at  any  rate  be  employed  from  a  therapeutic  point 
of  view.  The  following  suggestions  will  prove  helpful  to  differentiate 
hydrocephalus  from  macrocephalus  associated  with  hypertrophy  of 
the  brain. 

Hypertrophy   of  the   Brain  Hydrocephalus 

The  cranial  bones  are  usually  normal  in  Usually  the  reverse 

consistency :   the  enlargement   develops 

slowly 
Marked  pulsation  at  the  anterior  fontan-  Slight,  if  any 

elle 
Sutures   slightly   disconnected  Widely  gaping 

Ordinarily     normal     mentality     or     only  Idiocy  as  a  rule 

slight    deficiency 
Slight  intracranial  pressure — if  the  fon-  Very  marked 

tanelles  are  open 

Paralytic  Amentia 

(Vascular,  Inflammatory,  Toxic,  Meningitic,  or  Epileptic  Amentia) 
Under  this  heading  are  generally  grouped  the  numerous  cases  of 
mental  deficiency  which  are  due  to  more  or  less  extensive  lesions  in  the 
brain  occurring  either  before  and  during  birth  of  the  child  or  in  the 
course  of  his  first  few  years  of  life.  The  cerebral  lesions  may  be  the 
result  of  hemorrhage  or  inflammation,  or  both,  accompanying  prenatal, 
natal  or  postnatal  cranial  traumatism,  asphyxia  neonatorum,  meningi- 
tis, encephalitis,  influenza,  measles,  scarlet  or  typhoid  fever,  pertussis 
and  similar  microbic  affections,  and  neoplasms.     In  the  great  majority 


AMENTIA  713 

of  these  cases  the  cranial  bones  are  reduced  in  thickness,  the  meninges 
are  adherent,  and  some  of  the  convolutions  are  compressed,  atrophied 
and  indurated.  Some  portions  of  the  brain  are  in  a  state  of  softening, 
others  are  found  to  have  undergone  cystic  degeneration,  cicatricial  con- 
traction and  sclerosis.  The  lesions  are  productive  of  variable  clinical 
pictures  in  different  individuals.  They  may  lead  to  paralysis  in  one 
child,  convulsions  in  another,  and  to  amentia  in  the  third,  or  to  all 
these  manifestations  in  one  and  the  same  child.  Moreover,  these  phe- 
nomena are  not  invariably  correlated  to  the  extent  of  the  lesions.  And 
one  is  occasionally  surprised  to  find  diffuse  lobular  sclerosis  of  the 
brain  with  extensive  blcod  cysts  and  porencephaly  in  a  child  who  dur- 
ing life  was  apparently  endowed  with  fairly  normal  mental  faculties, 
and,  conversely,  only  minute  cerebral  lesions  with  total  idiocy.  As  a 
rule,  however,  in  infants  any  seemingly  trivial  intracranial  accident 
is  followed  by  mental  deficiency,  hemiplegia  or  diplegia,  and  this  is 
especially  the  case  with  lesions  in  the  frontal,  prefrontal  and  parietal 
lobes. 

Of  55  cases  of  hemiplegia  examined  by  Sachs  and  Peterson,  the  men- 
tal impairment  was  feeblemindedness  in  16  children,  imbecility  in  31, 
idiocy  in  7  and  epileptic  insanity  in  1  case.  In  diplegia  the  percentage 
of  mental  deficiency  is  always  very  high,  between  60  and  75,  whereas 
in  cerebral  paraplegia,  which  condition  is  usually  associated  with  less 
extensive  lesions,  the  mental  deficiency  is  rarely  very  pronounced. 
Epilepsy,  especially  of  the  Jacksonian  type,  is  quite  a  common  sequel 
of  cerebral  hemorrhage  or  inflammation  and  ultimately  ends  up  with 
progressive  amentia. 

In  order  to  obtain  a  clearer  conception  of  the  symptom  complexes  that 
usually  follow  the  aforementioned  pathologic  alterations  in  the  brain,  it 
is  advantageous  to  classify  these  eases  in  three  large  groups,  in  accord- 
ance with  the  time  of  their  development,  either  before,  during  or  after 
birth.  The  first  group  usually  reaches  this  world  in  a  more  or  less  ab- 
normal physical  condition.  These  children  are  often  prematurely  born, 
emaciated  and  disfigured,  and  of  very  low  vitality.  The  head  is  either 
small  and  asymmetrical  or  normal  in  size,  but  soft  and  flattened  on  one 
side.  The  extremities  are  either  rigid  or  slightly  movable,  or  there  may 
be  mono-,  para-,  or  diplegia.  (See  Fig.  211.)  As  these  symptoms  are 
the  result  either  of  arrested  development  of  the  brain  or  cord,  or  of 
both,  or  hemorrhagic  or  inflammatory  processes  therein,  it  is  not  at 
all  uncommon  to  find  several  cranial  nerves  implicated.  Under  these 
conditions,  of  course,  the  diagnosis  of  congenital  paralytic  amentia 
is  self-evident.  The  second  group  is  generally  described  as  Lit- 
tle's   disease,    or    diplegia    or    paraplegia    spastica    infantilis.      (See 


714 


DISEASES    OF    CHILDREN 


p.  61.5.)  Ill  the  great  majority  of  these  cases  there  is  a  history 
of  natal  traumatism,  asphyxia,  convulsions  immediately  after  birth 
and  other  signs  of  acute  cerebral  involvement.  (See  Fig.  213.) 
These  cases,  in  addition  to  the  characteristic  physical  syndrome,  fre- 
quently present  mental  deterioration,  ranging  from  simple  feeble-mind- 
edness  to  total  idiocy,  and  are  often  accompanied  by  stammering, 
nystagmus,  strabismus,  athetosis  and  epileptic  convulsions.  The  third 
group  of  cases  gives  a  history  of  apparently  normal  physical  and  mental 


Fig.  211. — Paralytic  idiot  of  antenatal  origin. 


development  at  birth,  and  of  an  acute  or  insidious  onset  of  some  febrile 
or  wasting  disease,  or  of  traumatism  some  time  after  birth,  which  was 
later  followed  by  amentia  with  or  without  paralysis  or  epilepsy,  and 
often  by  degeneration  of  the  cranial  nerves.  The  mental  impairment  is 
usually  progressive  in  character,  and  in  older  children  may  not  be 
fully  recognized  until  several  months  or  years  after  the  accident  or 
termination  of  the  primary  affection.  To  this  group  of  cases,  encephali- 
tis and  meningitis  and  their  prolific  sequelae,  more  especially  partial  or 


AMENTIA 


715 


total  deaf-mutism  and  blindness,  contribute  the  greatest  number  of 
victims,  although  traumatism  with  its  great  tendency  towards  epilepsy 
is  exceedingly  conspicuous  in  the  histories  of  postnatal  amentia  re- 
corded. According  to  Fletcher  Beach,  other  infectious  diseases,  such 
as  typhoid,  scarlet  fever  and  measles  do  not  form  very  rampant  causes 
of  this  variety  of  amentia,  for  after  examining  the  history  of  2,000  cases 
of  idiocy,  imbecility  and  feeble-mindedness  he  found  only  37  (or  1.85 
per  cent)  which  could  be  traced  to  an  attack  of  one  of  those  affections. 
In  connection  with  paralytic  amentia  it  is  opportune  to  call  attention 
to  a  form  of  mental  backwardness  which  is  occasionally  encountered  as 
a  result  of  hereditary  syphilis.  As  has  already  been  stated  the  amentia 
may  appear  in  consequence  of  hydrocephalus  or  in  connection  with 


Fig.  212. — Paralytic  amentia  in  consequence  of  cerebral  hemorrhage  during  in- 
strumental delivery.  The  baby  died  at  the  age  of  two  and  one-half  years  from 
miliary  tuberculosis. 


mono-,  hemi-,  or  diplegia  consecutive  to  syphilitic  meningitis  or  en- 
cephalitis. More  rarely  the  foundation  to  the  amentia  is  estab- 
lished during  intrauterine  life  in  the  form  of  gummatous  infiltration 
and  sclerosis  of  the  brain.  In  this  event  the  child  is  born  with  all  the 
symptoms  corresponding  with  the  primary  lesion  in  the  brain,  e.  g., 
paralysis,  defective  vision  or  hearing,  or  involvement  of  other  cranial 
nerves.  Except  for  the  history  of  the  case  and  the  positive  Wasser- 
mann  reaction  there  is  practically  no  way  of  distinguishing  syphilitic 
from  nonsypbilitic  paralytic  amentia.  However,  irregular  enlarge- 
ment of  tlje  head,  particularly  Parrot's  nodes,  should  serve  to  arouse 
our  suspicion. 


716  DISEASES    OF    CHILDREN 

Amaurotic  Family  Idiocy'" 

Tliis  form  of  amentia  is  based  upon  specific  pathologic  alterations  in 
the  brain.  It  is  characterized  by  some  degeneration  in  the  cerebral 
white  fibers  throughout  the  course  of  the  pyramidal  tracts,  in  the  inner 
capsule,  crusta,  pons  and  medulla,  and  also  of  the  pyramidal  tracts  in 
the  lateral  as  well  as  the-  anterior  columns  of  the  cord.  Furthermore, 
the  same  changes  are  found  also  in  the  gray  matter  of  the  central  nerv- 
ous system —  in  the  cortex  of  the  brain,  in  the  cranial  nerve  rniclei,  and 
in  the  gray  matter  of  the  spinal  cord  down  to  the  lowest  lumbar  and 
sacral  segments.  Wm.  A.  Holden  has  further  established  the  fact  that 
the  changes  in  the  retina  are  identical  with  those  in  the  brain  and  cord, 
and  were  due  to  a  degeneration  of  the  retinal  ganglion  cells.  Hirsch, 
after  a  very  exhaustive  histologic  examination  of  several  cases  under 
his  care,  concluded  that  not  only  are  the  cells  of  the  cortex  of  the  brain 
affected  but  the  ganglion  cells  of  the  entire  nervous  system,  the  main 
features  being  a  condition  of  chromatolysis  and  other  degenerative  proc- 
esses of  protoplasm,  combined  with  considerable  swelling  of  the  cell 
body  and  displacement  of  the  nucleus  towards  the  periphery  of  the  cell. 
The  neuroglia  and  the  blood  vessels  are  found  to  be  perfectly  normal. 

Like  the  pathology,  the  physical  and  mental  characteristics  are 
entirely  pathognomonic.  The  apparently  normally  born  and  develop- 
ing infant  begins  to  fail  in  strength  as  it  reaches  the  age  of  six  or  eight 
months.  Although  not  losing  in  weight,  nay,  sometimes  even  gaining, 
it  is  noticed  that  the  baby  is  unable  to  hold  up  his  head,  to  sit  erect, 
firmly  to  grasp  objects  placed  in  his  hands,  and  even  forcefully  to  suck 
on  the  nipple  of  breast  or  bottle.  Simultaneously  with  the  muscular 
atony  the  baby  begins  to  lose  interest  in  his  surroundings,  fails  to  smile 
when  accosted  and  to  follow  bright  objects  to  which  his  attention  is  be- 
ing directed- — all  indicating  mental  deterioration.  "When  the  back- 
grounds of  the  eyes  are  examined  a  very  peculiar  retinal  image  is  ob- 
tained. Namely,  the  maculae  are  cherry  red  in  color  and  surrounded 
by  large  grayish  white  patches.  The  optic  nerves  are  atrophied  in  the 
great  majority  of  cases  and  there  is  often  also  strabismus  and  nystag- 
mus. These  eye  symptoms  gradually  lead  to  total  blindness,  and  the 
muscular  atony  rapidly  borders  on  paralysis.  Hearing  at  first  is  hyper- 
acute, but  in  the  later  stages  of  the  affection  becomes  obtuse.  At  this 
time  also  there  is  often  inordinate  "explosive  laughter,"  difficult  de- 
glutition and  a  marked  tendency  to  recurrent  convulsions.  In  one  case 
I  noted  pronounced  hirsuties  over  the  greater  portion  of  the  body.  Thus 
deprived  of  sight  and  partially  of  the  sense  of  hearing,  limp  and  lan- 


*Warren   Tay   described   this   affection   in    1881    as   a   purely   local    inner   eye   disease,   while   B. 
Sachs,   in    1887,   recogniEed  and   described  it   as  a   distinct   brain   affection. 


AMENTIA 


717 


o'uid  as  <i  result  of  tlie  over  iuei-easinji'  atony  of  its  inusculatnre,  the 
helpless  creature  gradually  loses  all  its  other  senses  and,  t'ortuiuitely, 
also  its  life.  This  usually  oeeurs  before  the  child  attains  two  years  of 
age.  More  recently,  Vog't  has  described  a  "juvenile"  form  of  amaurotic 
family  idiocy  which  begins  to  manifest  itself  at  a  later  age  and  runs  a 
more  protracted  course.  Its  identity  with  the  "infantile"  form  of  the 
disease,  however,  is  not  generally  conceded. 


Fig.  213. — Amaurotic  family  idiocy  in  baby  l-l  months  old.     Note  inability  to  hold 
up  its  head.     (See  also  Fig.  207.) 


Fig.   214. — Macular   change    (cherry-red   discoloration)    in   amaurotic    family   idiocy. 

(After  Tay.) 

As  its  term  indicates,  this  form  of  amentia  affects  several  members  of 
the  same  family  or  those  who  are  closely  related,  and  shows  a  very  strik- 
ing predilection  for  offspring  of  the  Hebrew  race,  more  especially  of 
immigrants,  from  Russia  and  Poland.  This  peculiar  family  predisposi- 
tion seems  to  confirm  the  view  held  by  Sachs  and  others  that  amaurotic 


718  DISEASES   OP   CHILDREN 

family  idiocy  is  due  to  a  congenital  arrest  of  development,  although  the 
"juvenile"  form  seems  to  point  to  a  toxemic  nerve  degeneration  of 
postnatal  origin. 

In  the  early  stages  of  the  disease  amaurotic  idiocy  may  readily  be 
mistaken  for  rachitis,  but  in  this  affection  the  pathognomonic  amaurotic 
eye  symptoms  are  absent  and  the  mental  deficiency,  if  there  be  any,  is 
very  slight.  Furthermore,  rachitis  usually  sets  in  more  frequently  in 
infants  over  ten  months  of  age  and  the  muscular  atony  of  the  trunk  and 
spinal  muscles  is  never  so  pronounced  as  to  produce  dropping  of  the 
head  backwards.  More  difficulty  may  be  experienced  in  differentiating 
amaurotic  family  idiocy  from  cerebral  neoplasms,  be  they  syphilitic, 
tuberculous  or  malignant.  I  recall  a  case  of  gliosarcoma  of  the  pons 
affecting  a  one-year-old  infant,  that  was  under  observation  of  several 
podiatrists  and  ophthalmologists  of  note  and  was  diagnosed  as  incipient 
amaurotic  family  idiocy,  none  of  them  even  suspecting  the  presence  of 
a  cerebral  tumor.  While  in  the  latter  affection  optic  atrophy  is  a  com- 
mon symptom,  there  is  never  a  cherry  red  discoloration  of  the  maculae. 
Furthermore,  in  tumor  the  muscular  atony,  paralysis  and  convul- 
sions are  most  apt  to  be  unilateral  in  the  beginning,  and  gradually  bi- 
lateral, while  in  the  amaurotic  all  the  symptoms  are  bilateral  right  from 
the  start.  In  early  infancy  Mongolian  and  amaurotic  idiocy  have  two 
cardinal  symptoms  in  common — namely,  protrusion  of  the  tongue  and 
general  muscular  atony,  which  may  lead  to  errors  in  the  diagnosis.  In 
such  cases  an  ophthalmoscopic  examination  is  decisive.  It  will  also  be 
found  that  in  amaurotic  amentia  the  tongue  protrudes  but  slightly  and 
inconstantly,  and  is  otherwise  normal  in  appearance,  the  reverse  being 
the  case  in  mongolism.  Furthermore,  in  the  latter  condition  the  hair 
is  wiry  and  the  hands  are  usually  spade-like,  and  the  mentality  defi- 
cient from  birth  on.  As  has  already  been  stated,  in  all  cases  of  doubt 
an  ophthalmoscopic  examination  should  invariably  be  resorted  to  be- 
fore arriving  at  a  positive  conclusion. 

Mongolism 

Except  for  the  proportionately  undue  smallness  of  the  pons,  me- 
dulla, and  cerebellum  in  relation  to  the  cerebrum  as  compared  wath 
those  of  normal  babies,  the  central  nervous  system  of  the  Mongolian 
idiot  shows  no  characteristic  lesions.  As  in  other  forms  of  amentia 
the  brain  is  immature  and  its  cells  are  imperfectly  developed.  With 
growth  of  the  body  as  a  whole  the  brain  too  attains  a  higher  state  of 
perfection,  but  is  never  capable  of  unfolding  the  faculties  of  normal 
intellect.  Mongolism  is  frequently  associated  with  anomalies  of  the 
thyroid  gland  (hence  were  formerly  often  described  as  "cretinoids"), 


AMENTIA  719 

and  of  the  heart,  and  not  rarely  with  general  tuberculosis.  There 
seems  to  be  an  etiologic  relationship  between  mongolism  and  syphi- 
litic heredity.  Sutherland,  for  example,  has  found  a  history  of  syph- 
ilis in  11  out  of  25  cases  of  mongolism  under  his  observation. 

This  form  of  amentia  was  first  described  by  J.  L.  Down  in  1866, 
calling  particular  attention  to  the  facial  resemblance  of  the  members 
of  this  group  of  idiocy  to  those  of  the  Mongolian,  Asiatic  races,  such 
as  the  Chinese,  Calmueks  and  Malays.  The  typical  Mongolian  idiot 
has  a  small  egg-shaped  (brachycephalic)  head,  covered  by  smooth,  or 
dry  frizzly  hair ;  small  aquiline  nose,  which  is  bound  laterally  to- 
wards the  eyes  by  distinct  vertical  or  semi-lunar  folds  of  skin  which 
cover  the  inner  angle  of  the  eye  (epicanthus) ;  triangular  nostrils: 
almond-shaped,  slanting,  often  prominent  eyes  with  speckled  irides 
and  eczematous  eyelids,  not  rarely  also  ectropion ;  flat,  usually  flushed 
expressionless  face,  with  high  cheek  bones;  distorted  ears;  high  nar- 
row palate;  cracked  more  or  less  protruding  tongue  with  markedly 
enlarged  papillae  (later  the  so-called  '^ scrotal  tongue")  ;  and  irregularly 
set,  discolored  teeth.  The  hands  are  flabby,  clumsy,  spade-like,  and 
the  thumbs  are  stubby  (due  to  atrophy  of  the  phalanges).  In  addition 
to  these  characteristics  the  Mongolian  idiot  generally  presents  marked 
laxity  of  the  articulations,  so  that  the  tips  of  the  fingers  may  be  hy- 
perextended  almost  to  touch  the  dorsi  of  the  hands,  and  the  feet  may 
be  brought  up  to  the  neck  and  ears  while  he  is  in  a  sitting  posture. 
The  little  fingers  are  usually  very  thin  and  curved  inward;  the  geni- 
tals ill-developed ;  the  skin  is  dry,  rough  and  hairy,  and  owing  to 
circulatory  disturbances  the  Mongolian  idiot  often  suffers  from  chil- 
blains and  cracked  lips  which  are  kept  raw  by  the  dribbling  saliva. 
He  is  seldom  free  from  hypertrophied  adenoids  and  their  sequelae,  i.  e., 
nasopharyngitis,  bronchitis  or  even  recurrent  pneumonia.  The  latter 
may  possibly  be  also  due  to  the  frequently  accompanying  rachitis,  more 
especially  chicken  breast,  large  abdomen  and  spinal  curvature. 

Notwithstanding  all  their  troubles,  Mongolian  idiots  are  of  a  happy 
disposition,  placid  and  affectionate,  and  fond  of  music.  For  this 
reason  parents  often  fail  to  recognize  the  abnormal  state  of  their 
children,  even  though  they  note  their  general  bodily  weakness,  more 
particularly  their  inability  to  sit  erect,  to  stand  and  Avalk.  At  about 
two  years  of  age  these  aments  usually  become  more  active,  vivacious 
(always  "on  the  go"),  mischievous,  full  of  grimaces  and  facial  con- 
tortions— roften  misleading  the  parents  to  believe  that  they  had  out- 
grown their  tardy  development,  and  even  to  assume  that  their  chil- 
dren were,  exceptionally  bright.  However,  as  time  goes  on,  it  is 
generally  found  that  their  mentality  is  practically  at  a  standstill,  that 


720 


DISEASES   OF   CHILDREN 


they  can  rarely  understaiul  when  .s])()k(Mi  to  and  mucli  less  are 
able  to  speak.  It  is  not  uncommon  to  meet  with  ]\r()n<>()lian  idiots, 
two  or  three  years  old,  barely  able  to  repeat  single  syllables,  to  feed 
themselves  even  with  the  fingers  (tendency  to  gobble  down  the  food), 
or  to  respond  to  Nature's  calls.  As  they  get  older  they  learn  to  walk 
and  to  make  themselves  understood,  and  after  suitable  training,  to 
make  themselves  useful  and  to  perform  little  acts  for  their  personal 
comfort,  but  they  always  remain  in  a  primitive  mental  as  well  as 
physical  state  of  development ;  unreasonable,  helpless,  awk^vard  and 
uncleanly,  often  acquiring  vicious  habits  (e.  g.,  masturbation)  which 
help  to  undermine  their  frail  constitutions. 

"With  this  clinical  picture  in  view,  there  ought  to  be  no  difficulty  to 
distinguish  typical  mongolism  from  similar  forms  of  amentia.  Atypical 
cases,  however,  may  be  mistaken  for  cretinism,  microcephalus  and  rachitis. 


Fig.  215. — Mongolian  idiot  of  23  months,  Calmuck  type. 


In  microcephalus  the  idiocy  is  more  pronounced,  the  head  either 
very  small  or  asymmetrical,  and  the  ability  to  make  free  use  of  the 
extremities  in  grasping,  standing  and  walking  appears  at  a  very  much 
later  age  than  in  the  Mongolian  idiot. 

Mongolism  differs  from  cretinism  in  the  following  particulars: 


Mongolism 
Skull  bracliycephalic 
Hair  straight,  or  wiry  and  abundant 
Skin  thin,  hairy  and  mottled 
Face  flushed,  vivacious 
Eyes  almond-shaped ;   epicanthus 
Tongue    narrow,    cracked 
Little  finger  curved  inward 
Thyroid    treatment    of    little    benefit,    if 
at  all 


Cretinism 
Quite  normal 
Fine  and  sparse 
Swollen  ''padded" 
Pale  and  apathetic 
Palpebral  fissures  horizontal 
Broad,   swollen,   pale 
Stumpy 
Very  beneficial 


AMENTIA  721 

We  can  readily  distinguish  rachitis  from  mongolism  by  the  fact 
that  in  this  affection  the  head  is  more  or  less  square,  soft  and  covered 
by  fine  hair  more  especially  along  the  occiput.  The  eyes  are  normal, 
the  face  is  pale,  the  tongue  is  neither  protruding  nor  cracked,  and  the 
fingers  are  normal  in  shape.  Rachitis  may  delay  the  cerebral  functions  for 
a  few  months,  but  the  powers  of  speech,  perception  and  voluntary  mo- 
tion are  intact,  and  the  mentality  of  the  rachitic  child  rapidly  im- 
proves with  the  amelioration  of  its  physical  condition. 

Finally,  let  me  emphasize  that  a  diagnosis  of  mongolism  should  not 
be  based  upon  the  infant's  physiognomy  alone,  for  occasionally  we 
may  be  confronted  by  a  baby  of  Mongolian  ancestry  who  may  be 
otherwise  perfectly  normal  in  body  and  mind. 

Cretinism,  Myxidiocy 

Thyroid  insufficiency  though  primarily  not  a  brain  affection  sooner 
or  later  gives  rise  to  degeneration  of  the  central  nervous  system, 
more  especially  of  the  cortical  cells.  In  congenital  cases  the  cere- 
brum is  usually  considerably  smaller  than  in  normal  children,  and  its 
convolutions  are  simplified ;  the  cerebellum  is  asymmetrical  and  its 
laminae  are  reduced  in  number.  It  is  not  rarely  associated  with  hyper- 
plasia of  the  pineal  gland,  the  hypophysis  and  thymus  gland,  show- 
ing Nature's  attempt  to  compensate  the  thyroid  insut^ciency  by  hy- 
peractivity of  similar  structures.  Pathologically,  we  distinguish  two 
forms  of  thyroid  insufficiency  which  lead  to  amentia.  1.  Athyreosis 
or  absence  of  the  thyroid  gland  which  is  generally  a  congenital  anom- 
aly, but  may  exceptionally  occur  as  a  result  of  traumatism  or  acci- 
dental extirpation  (cachexia  thyreopriva).  In  congenital  athyreosis 
the  gland  is  frequently  found  replaced  by  cysts  or  other  neoplasms. 
Occasionally  degenerated  (or  healthy!)  thyroid  tissue  is  implanted 
in  the  base  of  the  tongue.  2.  Hypothyreosis  or  deficiency  of  thyroid 
gland  which  may  be  of  antenatal  origin  (e.  g.,  congenital  goiter)  or 
develop  later  as  a  result  of  disease  or  traumatism.  To  this  group  be- 
longs also  the  endemic  form  of  goitrous  degeneration  of  the  thyroid 
which  prevails  especially  in  certain  sections  of  Switzerland,  Germanj^ 
Asia,  England,  Russia,  Hungary  and  America,  in  shut-up  valleys  of 
mountainous  districts,  and  is  supposed  to  be  due  to  some  toxic  sub- 
stances in  the  unboiled  drinking  water.*    That  goiter  is  not  uncommon 


*Note. — This  view  has  recently  been  disputed  and  a  number  of  clinicians  look  upon  endemic 
cretinism  as  an  infectious  disease.  In  this  connection  the  report  of  A.  Kutschera  (Wien.  klin. 
Wchnschr.,  No.  45,  1910)  is  of  considerable  interest.  He  relates  that  he  found  two  dogs  to 
develop  cretinism  who  shared  the  bed  of  their  mistress,  a  semicretin.  One  dog  was  completely 
idiotic,  could  not  bark  and  reacted  to  nothing.  It  had  dry,  brittle,  dirty  hair,  and  milk  teeth 
together  with  permanent  teeth.  After  removing  these  two  animals  the  author  put  in  the 
cretin's    bed    a    healthy    four-months-old    pup    of    healthy    parents.      After    three    months    this    pup 


722 


DISEASES    OF    CHILDREN 


in  very  young  infants  can  be  gathered  from  the  statistics  collected  by 
Demme,  who  among  643  cases  found  53  to  be  of  prenatal  origin,  37 
which  developed  in  infants  under  one  month  of  age,  59  between  two 
and  twelve  months,  and  35  between  thirteen  and  forty-eight  months. 
Postmortem  examination  discloses  in  cretinism  marked  alterations  in 
the  osseous  system.  The  cranial  bones  are  thickened,  the  diploe  is  di- 
minished, and,  according  to  Virchow,  the  sphenobasilic  suture  prema- 
turely closed.  The  long  bones  are  thick  and  short  and  often  markedly 
deformed.     As  in  other  forms  of  profound  amentia  there  is  in  cretin- 


Fig.  216. — Cretin  from  birth;  total  idiot.     Note  "trident  hand." 


ism  retarded  development  of  the  centers  of  ossification  of  the  earpals 
and  of  the  epiphyses  of  the  metacarpals  and  phalanges.  Section  of  the 
tubular  bones  usually  shows  an  invasion  of  fibrous  tissue  frqm  the 
periosteum  in  between  the  epiphyses  and  shaft,  thus  hindering  the 
growth  of  the  bones  in  length.  Around  the  base  of  the  epiphysis  there 
is  sometimes  a  sheath-like  prolongation  which  may  even  be  ossified  and 


developed  a  large  head,  and  ten  months  later  it  became  a  full  fledged  cretin  while  the  rest  of 
the  litter  of  the  same  parents  who  were  not  exposed  to  cretinic  infection  remained  perfectly 
normal.  A  second  animal  of  a  large  race,  which  could  not  conveniently  occupy  the  same  bed 
with  the  cretin,  also  developed  normally.  The  author,  therefore,  believes  that  cretinism  is 
transmissible  by  direct,  close  contact. 


AMENTIA 


723 


form  a  distinct  cup  around  the  epiphysis.  But  in  contrast  to  what  is 
observed  in  rachitis,  there  is  no  proliferation  of  cartilage  cells  near  the 
line  of  ossification.  The  same  overlapping  or  cupping  of  the  epiphyseal 
cartilages  is  noted  also  in  the  ribs  and  innominate  bones  and  in  the 
scapula. 

The  physical  and  mental  manifestations  of  cretinism  vary  greatly 
with  the  degree  of  thyroid  insufficiency.  Moreover,  they  set  in  at  a 
later  period  in  breast  fed  than  in  artificially  fed  infants,  owing  to  the 
fact  that  during  the  first  few  weeks  of  life  breast  fed  infants  receive  an 
ample  supply  of  thyroid  gland  substance  through  the  mother's  milk  to 
counteract  their  thyroid  insufficiency.  In  acquired  athyreoism  the 
characteristic  symptoms  of  cretinism  usually  appear  gradually,  but 
once  the  clinical  syndrome  is  completed,  it  is  practically  alike  in  the 
prenatal  as  well  as  in  the  postnatal  cases.  The  head  of  the  cretin  is 
either  normal  in  size  or  slightly  enlarged,  flat  and  plump  and  set  upon 
a  thick,  short  neck.     The  fontanelles  usually  remain  open,  the  forehead 


Fig.  217. — Normal  at  one  year. 


Fig.   218! — iSamo   case   as   Fig.   217   iiro- 
nounccd  cretin  at  eight  years. 


is  low,  and  the  root  of  the  nose  is  broad  and  sunken.  The  face  is  weak 
and  senile.  The  eyelids  and  lips  are  edematous  and  the  tongue  is  large 
and  "swollen"  and  hence,  ever  protrudes  from  the  half-closed  mouth. 
The  teeth  are  slow  in  coming  and  rapid  in  decaying.  The  abdomen  is 
greatly  distended,  often  marked  by  a  large  umbilical  hernia.  The  ex- 
tremities are  more  or  less  deformed  and  the  articulations  thickened. 
The  hands  and  feet  are  short  and  flabby.  Cretins  learn  to  walk  late, 
and  their  'gait  is  awkward  and  draggy.  The  skin  is  dry,  waxy  and 
doughy  in  consistency,  and  the  hair  is  sparse  and  brittle.     The  body 


724 


DISEASES   OF    CHILDREN 


temperature  is  generally  subnormal,  and  owing  also  to  the  ever  present 
anemia,  cretins  are  very  sensitive  to  cold,  notwithstanding  their  cor- 
pulent appearance.  "Fatty  tumors"  are  usually  found  in  the  supra- 
clavicular and  axillary  spaces. 

The  intelligence  of  the  infantile  cretin,  as  has  already  been  stated, 
varies  with  the  functionating  capacity  of  the  thyroid  gland.  In  con- 
genital athyreosis  there  is  total  idiocy  (myxidiocy).  Some  cretins,  the 
so-called  semicretins,  possess  a  fair  measure  of  intelligence.  They  ap- 
preciate their  surroundings,  and  are  able  to  acquire  a  meager  vocabu- 
lary which  may  be  ample  to  make  their  urgent  wants  understood,  or 


Fig.  219. — Same  case  as  Fig.  218  four  weeks  after  treatment  with  thyroid. 

even  to  reply  to  simple  questions.  On  the  other  hand,  where  the  thyroid 
insufficiency  is  marked,  they  never  reach  even  this  low  state  of  mental 
development,  and,  on  the  contrary,  get  more  stupid  as  they  grow  older. 
In  the  great  majority  of  cretins,  the  special  senses  are  implicated. 
Taste  and  smell  are  obtuse ;  hearing  is  defective  and  vision  dull.  The 
voice  of  the  cretin  is  ordinarily  husky.  Like  the  hydrocephalic  aments 
they  are  timid,  gentle  and  unassuming,  and  if  left  untreated,  they  re- 
tain their  childish  behavior  for  life. 

One  of  the  most  characteristic  features  of  cretinism  is  its  marvelous 
improvement  under  thyroid  feeding.  After  exhibiting  thyroid  gland  ex- 
tract in  one  form  or  another  for  but  a  short  time,  the  cretin  is  often  trans- 


AMENTIA  725 

formed  from  an  uncouth,  apathetic  and  clumsy  little  creature  into  a 
lusty,  gracile  and  growing  human  being.  Thus  the  blurred  facial  features 
gain  youthful  expression ;  the  lusterless,  withered  hair  takes  on  new 
life;  the  stunted  stature  shoots  up  to  almost  normal  proportions,  and 
the  brutal  stupidity  gradually  gives  way  to  human  intelligence.  How- 
ever, this  marvelous  transformation  lasts  only  as  long  as  the  thyroid 
medication  is  permitted  to  exert  its  wonderful  influence.     With  dis- 


Fig.  220. — Same  case  as  Fig.  218  teu  weeks  after  treatment  with  thyroid. 


continuance  of  the  treatment  the  cretin  slowly  but  surely  sinks  back 
into  his  everlasting  idiotic  condition. 

Total  athyreosis  in  the  early  stages  and  partial  cretinism  at  any  pe- 
riod of  early  childhood  may  be  confounded  with  severe  forms  of 
rachitis  and  mongolism.  The  differentiation  of  the  latter  form  of 
amentia  from  cretinism  has  already  been  discussed  in  connection  with 
the  former  affection.  (See  p.  720.)  In  distinguishing  cretinism  from 
rachitis  it  is  well  to  bear  in  mind  that  the  latter  may  complicate  the 
former  disease.  But  in  rickets  the  deficiency  of  intellect  is  slight  and 
not  progressive;  the  tongue  is  neither  large  nor  protruding;  the  skin 
is  soft  and  thin  and  not  rough  and  edematous ;  the  hair  is  normal  and  bald 


726  DISEASES    OF    CHILDREN 

only  ill  spots,  especially  over  the  occiput,  Avhereas  in  cretinism  tlic  hair  is 
brittle  all  over  the  scalp,  and,  finally,  the  rachitic  baby  learns  to  talk  early 
and  its  voice  is  perfectly  normal  even  thongli  it  may  be  weak.  Rachitis 
complicated  by  congenital  macroglossia  and  adenoids  may  on  very  rare 
occasions  lead  to  errors  in  the  diagnosis,  but  careful  inquiry  into  the 
history  of  the  case  and  the  exhibition  of  thyroid  extract  will  soon  clear 
up  all  doubts.  Furthermore,  it  will  generally  be  found  that  in  con- 
genital macroglossia  the  tongue  gets  gradually  relatively  smaller  as  the 
child's  mouth  grows  larger,  which  is  not  the  case  in  cretinism.  Besides, 
there  is  always  the  marked  difference  in  the  physical  and  mental  de- 
velopment of  these  children. 

Infantilism 

Under  this  heading  arc  generally  grouped  several  types  of  abnormal 
infants  who  never  attain  the  physical  and  mental  development  of  adults 
and  who  retain  several  characteristics  of  infants  and  j^oung  children 
throughout  life.  In  physiognomy  and  stature  infantilism  is  closely 
allied  to  cretinism,  and  in  many  instances  directly  dependent  upon 
thyroid  insufficiency.  Similar  clinical  syndromes  have  more  recently 
been  observed  in  connection  with  deficient  functions  of  the  thymus, 
adrenals,  pancreas,  and  pituitary  gland,  and  some  observers  claim  that 
similar  arrests  of  development  occur  as  the  result  of  systemic  poisoning 
by  the  syphilitic  germ  and  other  microorganisms.  In  accordance,  there- 
fore, with  the  aforementioned  etiologic  factors,  infantilism  may  be 
classified  in  the  following  types: 

Thyroid  infantilism, 
Thymus  infantilism. 
Pituitary  infantilism, 
Hcredosyphilitic  infantilism,! 
Dystrophic  infantilism. 
Cardiac   infantilism. 
Intestinal  infantilism. 
Malarial  infantilism, 
Pellagra  infantilism. 

Two  special  types  of  thyroid  infantilism  are  generally  encountered — 
namely,  typus  Brissaud,  which  is  characterized  by  fullness  of  the 
face,  plumpness  of  the  body  and  clumsy  extremities  (Fig.  221),  and 
typus  Lorain  whose  stature  is  gracile  and  whose  facial  features  are 
pleasant  and  comely  (Fig.  222). 

The  subject  in  question  is  as  yet  awaiting  considerable  elucidation. 
With  the  advance  of  our  knowledge  of  the  normal  and  abnormal 
actions  of  the  ductless  glands,  we  shall  undoubtedly  be  able  to  clas- 


fl   recently   saw   a   case   of   this   tytJe   weighing  only   29   pounds   at   nine   years. 


AMENTIA 


727 


sify  infantilism  in  two  large  groups,  thus:  Genuine  infantilism,  em- 
bracing all  cases  in  -which  mental  deficiency  predominates,  and  a 
second  form  of  infantilism,  which  is  being  described  as  microsomia, 
nanosomia,  ateliosis,  asthenia,  achondroplasia  and  Herter's  infantilism, 
in  all  of  which  physical  arrest  of  development  predominates.  I  may 
state,  by  the  way,  that  contrary  to  what  is  frequently  recorded  in 


rj 

^^^^^H 

1 

i 

^.1 

y 

fm 

1          1 

k 

3 

Fig.  221. — Infantilism,  Brissaud  type, 
six  years  old;  measures  32  inches  in 
length. 


Fig.  222. — Infantilism,  typus  Lo- 
rain, four  and  one-half  years  old;  meas- 
ures 32  inches  in  height  and  weighs  28 
pounds,  acts  like  a  two-year-old  infant. 
Note  absence  of  left  thumb  and  rudi- 
mentary development  of  right  thumb. 


medical  literature,  so-called  Herter's  infantilism  is  not  associated 
with  actual  mental  deficiency.  To  quote  this  author:  "The  intelli- 
gence of  these  patients  was  in  every  instance  good,  although  the  ne- 
cessity of  living  very  carefully  and  obeying  the  directions  of  the 
physician,  and  nurse  has  tended  to  make  these  children  somewhat 
introspective  as  regards  their  own  ailments  and  to  form  the  basis  of 


728  DISEASES    OF    CHILDREN 

what  might  with  increasing  consciousness  develop  in  after  life  into 
a  hypochrondriacal  condition." 

Congenital  infantilism  like  congenital  idiocy  in  general  is  often  as- 
sociated with  physical  stigmata  of  degeneration.  Atrophy  of  the 
genitalia  is  particularly  common  where  the  ductless  glands  are  in- 
volved. (See  Frohlich's  Syndrome,  p.  570.)  As  in  the  idiot,  we  often 
find  retarded  development  of  the  carpi  also  in  infantilism.  (See  Fig. 
223.)  The  mentality  of  these  children  is  very  variable  and  depends 
entirely  upon  the  period  of  life  at  which  their  mental  development 


Fig.  223. — Left,  wrist  of  ament  10  years  old;  right,  wrist  of  normal  child  six  years 
old.    Note  greater  number  of  carpi  in  the  latter. 

has  been  arrested.  As  a  rule,  they  are  never  totally  idiotic,  and  the 
majority  of  them  are  able  to  help  themselves,  to  walk  about  and  to 
play,  and  to  understand  a  simple  conversation.  Speech  is  usually  de- 
layed, but  with  advancing  age  and  proper  training,  they  ordinarily 
learn  to  speak,  as  well  as  to  count,  to  write,  and  to  earn  a  modest  live- 
lihood. 

Moramentia" 

(Retarded  Mentality) 

Delayed  mental  development  is  quite  frequently  the  result  of  the 
following  causes:  (1)  Deprivation  of  special  senses,  e.  g.,  sight  and 
hearing;  (2)  chronic  affections,  such  as  heart  disease,  and  other  severe 
nutritional  disturbances;  (3)  faulty  environment  and  education,  or 
isolation. 


*For  this  group  of  cases  mora-mcntia  would  be  a  very  appropriate  term  ;  mora  (ae)   signify- 
ing delay,  impediment,  hindrance,  and  mentia  being  used  to  designate  mentality. 


AMENTIA 


729 


Sense  deprivation  as  a  cause  of  retarded  mentality  need  not  be  com- 
plete. Mere  errors  of  refraction,  for  example,  by  leaving  the  child  ig- 
norant of  numerous  objects  outside  its  field  of  vision,  may  be  entirely 
sufficient  to  delay  the  unfolding  of  its  mental  faculties.  Similarly  do 
we  find  that  an  infant  afflicted  with  adenoids,  which  interfere  with  acute 
hearing  and  render  it  listless  and  inattentive,  at  least  temporarily  fails 


Fig.  224. — Moramontia  in  a  two-year-old  boy,  as  a  result  of  marked  adenoids  with  its 
consequences,  especially  difficult  hearing. 

to -receive  the  outside  impulses  to  the  brain  and  hence  remains  mentally 
backward.  These  children,  however,  are  not  suffering  from  amentia  in 
the  true  sense  of  the  word.  On  the  contrary,  experience  teaches  that 
just  as  soon  as  the  retarding  elements  are  removed,  e.  g.,  removal  of  the 
adenoids  and  correction  of  the  visual  defects,  the  supposedly  mentally 
deficient  children  rapidly  reach  a  normal  state  of  mental  development. 


730  DISEASES   OF    CHILDREN 

Defective  vision,  particularly  if  congenital  in  nature  {c.  g.,  congenital 
cataract)  or  acquired  soon  after  birth,  forms  a  greater  impediment  to 
normal  mental  development  than  a  similar  defect  in  the  sense  of  hear- 
ing. It  is  quite  common  to  meet  with  very  intelligent  deaf-mutes  who 
by  means  of  lip-reading  or  dactylology  even  in  early  childhood  are  able 
to  make  themselves  understood  and  fully  to  express  their  wants. 
Very  recently  two  deaf-mutes,  brother  and  sister,  came  under  my  ob- 
servation, who  for  intelligence  could  pass  muster  as  any  normal  children 
of  the  same  ages.  Their  parents  were  first  cousins,  and  their  father 
was  fifteen  years  older  than  the  mother.  The  little  girl  was  eight  years 
and  the  brother  two  years  old.  They  had  another  brother,  who  was 
able  to  hear,  and  to  speak,  but  died  at  the  age  of  five  years  during  an 
attack  of  pneumonia.  It  was  a  most  pathetic  sight  to  watch  the  two 
children  by  means  of  dactylology  and  lip-language  to  converse  among 
themselves  or  with  their  mother,  and  it  was  astonishing  how  much  in- 
formation the  mother  was  able  to  convey  to  the  little  baby.  The  older 
child  was  full  of  life  and  possessed  of  powers  of  observation  and  imagi- 
nation rarely  to  be  met  with  in  perfectly  normal  children  of  her  age. 
While  examining  her  she  was  intently  interested  in  everything  I  was 
doing,  and  as  I  was  testing  her  hearing — hoping  possibly  to  detect  a 
trace  of  it  intact — she  concentrated  her  whole  mind  upon  the  test,  and 
off  and  on  gleefully  announced  to  her  mother  that  she  was  capable  of 
hearing — poor  child,  she  was  carried  away  by  her  vivid  imagination ! 
And  I  shall  never  forget  her  literally  shining  face  and  the  grateful, 
almost  overflowing  eyes,  when,  to  please  her,  she  was  assured,  that  her 
condition  was  not  hopeless,  and  that  it  was  merely  a  matter  of  time 
when  she  would  learn  both  to  hear  and  to  speak. 

The  mental  deficiency  encountered  in  children  suffering  from  some 
chronic  organic  affections  or  nutritional  disturbances  (e.  g.,  rachitis), 
like  that  associated  with  the  aforementioned  deprivation  of  the  senses, 
is  only  relative  in  character.  In  those  children  the  brain  possesses  every 
potentiality  for  normal  growth  and  development,  but  remains  in  a  state 
of  passivity  for  want  of  prerequisite  outside  impressions.  This  is  due 
to  the  fact,  on  the  one  hand,  that  sickly,  depressed  children  are  not  at 
all  inclined  to  bother  with  what  is  transpiring  around  them,  and,  on  the 
other  hand,  parents  justly  refrain  from  burdening  sickly  children  with 
any  sort  of  training  and  education.  That  deficient  or  disturbed  nutri- 
tion, per  se,  is  not  a  potent  factor  in  the  production  of  amentia,  can 
readily  be  proved  by  watching  the  acuity  of  perception  of  emaciated 
so-called  marasmic  babies.  Nothing  that  bears  a  semblance  of  food  or 
its  container  escapes  their  attention,  and  they  show  a  wonderful  dex- 
terity in  manipulating  the  nipple  or  bottle  at  a  very  early  age. 


AMENTIA 


731 


Faulty  environment  and  isolation,  similar  to  deprivation  of  the  senses, 
greatly  retards  mental  elaboration  owinj;  to  lack  of  cerebral  impres- 
sions by  outside  influences.  We  can  hardly  expect  a  young  child  to 
distinguish  objects  it  never  had  a  chance  to  see  or  to  touch ;  and  the 
unfortunate  child  who  happens  to  be  cursed  with  a  habitually  intoxi- 
cated father,  mother  or  both,  and  daily  sees  before  him  smashed  heads 
and  smashed  dishes,  and  hears  profanity  on  the  one  hand  and  incohe- 
rent babble  on  the  other,  is  certainly  ill  prepared  to  acquire  the  attri- 
butes of  normal  mentality,  and  to  show  affection,  power  of  imagination. 


Fig.  225. — Moramcntia,  as  a  result  of  isolation  and  faulty  environment. 


judgment  and  discrimination.  Faulty  environment  and  isolation  are 
not  invariably  the  sad  lot  of  the  children  of  the  poor  and  the  degenerate. 
I  have  met  with  many  a  baby  of  fashion  under  two  years  of  age  or 
older,  who  at  first  impressed  me  as  being  utterly  idiotic  and  who  had 
remained  mentally  backward  for  several  months  thereafter,  because  of 
their  having  been  secluded  in  some  remote  corner  of  their  nurseries  or 
huddled  away  under  the  upholstered  hood  of  their  carriages,  and  thus 
were  given  no  opportunity  to  exercise  their  musculature  or  brain  matter. 
Only  too  often  do  we  see  infants  of  the  rich  entrusted  to  the  care  of 
some  inexperienced,  half-baked,  "white  linen  nurse,"  who  considers  it 


732  DISEASES   OF    CHILDREN 

her  greatest  achievement  to  keep  the  baby's  bowels  regular  and  who  has 
not  the  slightest  conception  of  the  importance  of  early  mental  develop- 
ment. But  as  has  previously  been  stated,  this  group  of  mentally  back- 
ward children  of  the  poor  as  well  as  of  the  rich,  when  by  Nature  en- 
dowed with  normal  brains,  wdth  marvelous  celerity,  they  retrieve  the 
dormant  mental  faculties  if  placed  in  desirable  surroundings  and  given 
the  benefit  of  sensible  management. 

Prophylaxis 

The  aforementioned  theoretic  consideration  of  idiocy  and  the  allied 
mental  deficiencies  in  childhood  tend  greatly,  I  believe,  to  establish  the 
facts,  first,  that  amentia  is  preventable  in  a  large  proportion  of  cases, 
if  prophylactic  measures  are  instituted  early;  secondly,  that  under 
suitable  management  a  great  many  mentally  deficient  children  can  be 
made  useful  to  themselves  and  possibly  also  to  the  commonwealth.  We 
shall  now  endeavor  to  offer  a  few  practical  suggestions  to  accomplish 
this  highly  desirable  object  in  view. 

One  of  the  most  essential  factors  in  the  prevention  of  mental  debility 
in  the  offspring  is  their  inherent  bodily  and  mental  strength.  Inherent 
strength  is  not  procurable  after  birth.  As  stated  it  is  a  consummation,  an 
inheritance  of  ancestral  virility  and  vigor,  premarital  purity,  conjugal 
devotion,  matrimonial  chastity,  sobriety  and  ideal  hygiene.  It  can  be 
fostered  by  sensible  regulation  of  marriage,  conservative  mutual  selec- 
tion, avoidance  of  consanguineous  mating  and  prohibition  of  marriage 
among  those  encumbered  by  chronic  brain  affections,  grave  wasting 
diseases,  alcoholism,  drug  habits  and  extreme  poverty.  Above  all,  in- 
herent strength  can  be  fostered  by  judicious  management  of  pregnancy, 
labor  and  the  physical  and  mental  care  of  the  infant.  Within  recent 
years  there  has  been  a  great  awakening  to  the  importance  of  exacting 
from  those  destined  to  procreate  the  race  of  the  future  that  they  be 
free  from  all  encumbrances,  congenital  as  well  as  acquired,  which  tend 
to  embarrass  their  offspring  in  their  normal  development.  And  while 
eugenics,  as  at  present  taught,  carries  with  it  a  good  deal  of  useless, 
nay  harmful,  fiction  and  fetichism  which  veil  its  true  object  and  render 
it  subject  to  ridicule  and  derision,  there  is  every  reason  for  the  belief 
that  after  the  noisy  agitation  has  ceased  and  thorough  sifting  of  the 
good  from  the  bad  has  taken  place,  the  world  will  be  very  much  the 
better  for  it.  In  the  meantime,  or  until  the  lustrous  millennium  has 
dawned  upon  us,  it  is  entirely  sufficient  for  physicians  to  preach  practi- 
cal rather  than  theoretic  eugenics  and  to  counsel  those  encumbered 
by  grave  hereditary  taints  to  be  very  cautious  in  the  selection  of  their 
mates,  lest  doubly  marred  heredity  may  intensify  the  degeneracy  in  the 


AMENTIA  733 

offspring.  All  agree  that  those  suffering  from  specific  venereal  disease, 
tuberculosis,  malignant  disease,  epilepsy  and  insanity  are  not  marriage- 
able subjects,  and  should  not  be  permitted  to  marry,  unless  they  can 
show  that  they  have  remained  free  from  any  traces  of  these  affections 
for  a  number  of  years.  But  it  is  not  in  the  province  of  the  physician  to 
join  the  eugenists  in  their  hunt  for  "desirable  types"  of  man-  or  woman- 
hood, even  were  such  types  at  all  desirable.  "What  the  eugenists  set 
up  as  desirable  types,"  says  A.  C.  Jacobson,  "strikes  many  of  us  as 
merely  smug,  unctuously  respectable  and  commonplace  paragons.  If 
the  eugenists  had  their  way  and  succeeded  in  peopling  the  world  with 
a  race  of  disgustingly  normal  beings,  standardized  to  the  Philistian 
scale  which  the  intellectual  plebeians  who  are  so  warmly  drawn  to- 
wards the  eugenic  camp  seem  determined  to  devise,  life  would  be 
drab  and  jejune  indeed.  Happily  such  a  consummation  can  never  be, 
for  which  the  gods  be  thanked.  Anything  approaching  real  control 
of  the  race  after  the  plan  of  these  fanatical  breeders  is  a  phantasy 
*  *  *  since  haphazard  'scrub-breeding'  has  gone  on  in  the  human 
family  so  long  that  pure  strains  with  definite  character  units  are 
practically  unknown.  Hence,  who  is  the  fit?  What  is  fitness"? 
Physicians  can  do  most  good  by  judicious  management  of  pregnancy 
and  labor,  and  the  rearing  of  the  child,  more  especially  during  its  first 
few  years  of  life.  As  has  already  been  stated,  after  impregnation  the 
destiny  of  the  offspring  is  partially  or  wholly  dependent  upon  the 
physical  and  mental  welfare  of  the  mother.  "But  even  if  it  be  proved 
— it  has  not  yet  been  proved — that  the  conditions  of  life  in  the  nine 
months  before  birth  have  no  influence  either  for  good  or  ill  upon  hered- 
itary maladies  and  deformities,  even  then  there  remains  much  to  be 
done  in  antenatal  hygiene,  for  there  cannot  be  the  slightest  doubt  that 
many  morbid  influences  come  to  play  upon  the  body  of  the  infant  in  the 
womb  and  that  some  at  least  of  them  may  be  prevented  or  their  results 
cured"  (Ballantyne).  No  definite  statistics  have  thus  far  been  ad- 
duced to  show  the  degree  or  extent  of  the  beneficial  influence  of  ante- 
natal hygiene  upon  the  mentality  of  the  offspring,  but  some  approxi- 
mate estimate  can  be  obtained  by  analogy,  when  we  compare  the  weight 
and  physical  power  of  resistance  of  babies  born  under  favorable  condi- 
tions with  those  born  of  mothers  who  up  to  the  last  moment  of  preg- 
nancy were  exposed  to  hardship  and  struggle  for  existence.  Thus,  Pinard 
gives  as  the  average  weight  of  babies  of  women,  who  worked  up  to  the 
time  of  delivery,  about  6i/^  pounds'  while  for  those  born  of  women,  who 
had  a  short  respite  from  hard  work  before  delivery,  71/4  pounds.  Borde 
found  the  average  weight  of  babies  of  Italian  women,  who  worked  up 
to  the  delivery,  to  be  6I/4  pounds,  while  of  those,  who  had  rested  a  few 


734  DISEASES   OF   CHILDREN 

weeks  before  delivery,  about  7  pounds.  More  recently  S.  Poller  re- 
ported his  findings  among  Austrian  women.  His  material  was  drawn 
from  two  sources,  a  sanatorium  for  women  of  means  with  612  patients, 
and  a  large  clinic  for  poor  women  (under  the  direction  of  L.  Teleky) 
with  4,875  cases.  He  found  that  the  first  born  male  babies  of  well-to-do 
women  averaged  about  4  ounces  heavier  and  the  female  babies  about  3 
ounces  heavier  than  the  babies  of  poor  women  who  worked  up  to  con- 
finement. Moreover,  in  a  comparison  of  the  first  born  children  of 
hospital  women  with  those  of  the  women  coming  to  the  hospital  just 
before  confinement,  the  babies  of  the  former  are  shown  to  average  about 
4  ounces  heavier  than  these  of  the  latter  group. 

With  these  observations  in  view  the  importance  of  antenatal  hygiene 
for  the  betterment  of  the  race  of  the  future  becomes  self-evident.  The 
prospective  mother  should  be  placed  in  a  wholesome  environment  and 
proper  hygienic  surroundings.  Her  diet  should  be  liberal,  her  living 
rooms  spacious,  and  airy,  and  her  association  cheerful.  Wherever  possi- 
ble, she  should  be  free  from  the  anxieties  of  earning  a  livelihood  or  the 
pompous  frivolities  of  wanton  society.  The  boundless  extravagancies 
of  extreme  wealth  and  the  awful  misery  of  extreme  poverty,  both  alike, 
sap  the  vital  forces  of  the  mothers  as  well  as  of  their  offspring.  The 
State,  if  need  be,  should  provide  for  the  poor  expectant  mother  at  least 
a  few  weeks'  respite  from  hard  work  previous  to  delivery  and  also 
thereafter.  We  must  allay  the  anxiety  of  the  primapara  by  assuring 
her  that  pregnancy  and  parturition  are  physiologic,  normal  processes, 
under  proper  management  devoid  of  perilous  complications  and  sequelse ; 
and  the  multipara  should  be  impressed  with  the  fact  that  miscarriages 
and  attempted  abortions  are  dangerous  experiments,  one  tending  to 
interfere  with  normal  development  of  the  offspring  that  are  to  come 
later  (by  leaving  the  uterus  in  a  more  or  less  permanently  diseased 
state),  the  other  actually  injuring  the  embryo  or  fetus  during  the  proc- 
ess of  growth  and  development. 

Next  to  antenatal  hygiene  the  judicious  management  of  labor  serves 
as  the  most  important  means  in  the  prevention  of  amentia  in  the  off- 
spring. Judging  by  the  appalling  number^  of  cases  of  paralytic  amentia 
following  traumatism  during  birth,  and  considering  the  fact  that  the 
cases  recorded  form  but  an  infinitesimal  portion^  of  the  innumerable 
cases  that  never  see  light  after  delivery  or  survive  the  injuries  sus- 
tained but  a  few  days  or  weeks,  there  must  be  something  very  seriously 


iL,apage  reports  25  out  of  96  cases  of  amentia  under  his  observation;  Still  26  out  of  135; 
my   own  records  show  30  cases   out  of   119. 

^In  Philadelphia,  for  example,  out  of  39,975  births  during  the  year  of  1911,  2,131  were  still- 
born; and  according  to  the  annual  report  of  Miss  Julia  C.  Lathrop,  out  of  300,000  infants  under 
one  year  who  succumbed  during  1911,  about  30  per  cent  did  not  live  to  complete  the  first 
month  of  life  as  a  result  of  j)renatal  conditions  or  of  injury  and  accident  during  birth  ! 


AMENTIA  735 

wrong  with  the  way  midwifery  is  being  practiced  even  in  the  civilized 
parts  of  tlie  workl.  Due  allowance,  of  course,  must  be  made  to  the  fact 
that  in  this  country  the  women  who  furnish  the  greatest  number  of 
births  are  of  foreign  birth  and  bringing  up,  and  owing  to  mistaken 
prudery  still  cling  to  the  custom  of  their  mothers  and  depend  upon  ig- 
norant midwives  for  the  performance  of  the  vital  function  of  obstetri- 
cian. But  it  is  high  time  that  each  state  or  the  Federal  government 
should  put  a  limit  to  this  much  abused  "personal  liberty"  clause  and 
insist  upon  only  licensed  midwives  (after  practical  examinations)  being 
permitted  to  practice  obstetrics,  in  order  to  safeguard  the  future  welfare 
of  the  children  as  well  as  of  the  mothers,  not  to  speak  of  the  economic 
benefits  to  their  respective  communities.  Medical  men  also  ought  to 
awaken  to  the  gravity  of  the  situation,  and,  on  the  one  hand,  refrain 
from  the  hasty  application  of  instruments  in  ordinary  cases,  and,  on 
the  other  hand,  in  difficult  labors  not  to  hesitate  to  invoke  the  assistance 
of  competent  obstetricians,  who  through  skillful  manipulation  might 
possibly  be  able  to  prevent  cranial  injury,  asphyxia,  etc.  in  the  infant, 
which  so  frequently  lead  to  cerebral  diplegia  with  amentia.  Pituitary 
extract,  the  most  recent  addition  to  the  obstetrician's  armamentarium, 
which  in  appropriate  cases  seems  to  exert  an  almost  magical  effect  upon 
inertia  uteri,  will  undoubtedly  greatly  help  to  dispense  with  instru- 
mental delivery  and  thus  to  diminish  the  number  of  aments  due  to  this 
cause. 

As  regards  the  postnatal  care  of  the  infant  in  the  prevention  of  mental 
deficiency,  let  me  urge  upon  physicians  ever  to  remember  that  their 
sphere  of  usefulness  does  not  end  with  the  perfunctory  manipulation 
of  the  stethescope  or  thermometer,  nor  even  with  the  punctilious  elabo- 
ration of  food-formulas,  diet  lists  or  recipes.  The  mentality,  das 
Sinnesleben,  (the  mind  activity,  or  the  senses)  of  the  child  should  enlist 
as  much  of  our  deliberative  attention  as  its  physical  condition,  more 
especially  when  there  is  a  tainted  family  history  or  an  environment  that 
is  conducive  towards  a  morbid  mentality.  And  while  it  surely  is  the 
physician's  paramount  duty  to  safeguard  the  physical  welfare  of  the 
child,  it  is  no  less  important  for  us  to  guide  its  mental  destiny.  Indeed, 
strength  of  mind  quite  often  compensates  for  weakness  of  the  body, 
while  strength  of  body  only  very  rarely,  if  ever,  compensates  for  weak- 
ness of  mind. 

In  the  mental  training  of  infants  we  usually  meet  with  two  extremes. 
One  class  of  mothers  keeps  its  infants  in  a  state  of  noli  me  tangere, 
hidden  in  the  remotest  corner  of  the  boudoir,  lest  it  be  bewitched  by  an 
' '  evil  eye, ' '  or,  as  they  say,  unhinged  by  the  premature  sensitization  of 
the  brain;  the  other  class  of  mothers  injudiciously  strains  its  infants' 


736  DISEASES   OF    CHILDREN 

cerebral  functions  to  the  breaking  point,  makes  them  the  central  figures 
of  attraction  of  their  household,  teaches  them  to  sing  and  to  recite,  to  read 
and  to  write  at  a  very  tender  age,  when  they  are  barely  out  of  their 
bottling  period.  These  two  extremes  in  mental  training  should  reso- 
lutely be  discountenanced,  and  the  happy  medium  chosen.  The  in- 
fantile brain,  lik^  the  potter's  clay,  needs  moulding  while  it  is  fresh  and 
pliable,  but  it  must  be  mastered  skillfully  and  gently  to  avoid  exhaus- 
tion of  the  brain  cells  or  their  disarrangement.  The  mental  training 
should  begin  when  the  infant  is  about  three  months  old.  He  should  be 
picked  up  a  few  times  a  day,  put  on  the  lap  and  supported  with  the 
forearm,  and  shown  a  few  lustrous  things  to  stimulate  his  power  of 
vision  and  attention.  Gradually  some  object  should  be  put  in  his  hands 
to  train  him  to  grasp.  As  he  gets  a  little  older,  he  should  now  and 
then,  for  a  few  minutes  at  a  time,  and  properly  supported,  be  sat  up  in 
his  carriage  or  bed,  and  allowed,  as  it  were,  to  make  a  general  survey 
of  the  beautiful  world  and  the  grand  things  that  help  to  make  it  so.  At 
six  months  of  age,  if  strong  enough,  he  should  be  put  in  a  baby  chair, 
given  a  few  harmless  little  toys  to  play  with,  and  be  permitted  to  be  ac- 
costed by  some  intimate  friends  of  the  family,  in  order  to  get  the  child  ac- 
customed to  distinguish  strange  faces.  Some  few  months  later,  he  should 
be  gradually  taught  to  perform  some  simple  baby  tricks,  such  as  clap- 
ping hands,  and  the  like.  In  suggesting  these  procedures  I  do  not  at 
all  intend  to  convey  the  idea  that  every  kin  and  friend  of  the  family 
should  be  invited  to  exhaust  their  ingenuity  to  devise  means  to  enter- 
tain the  baby.  Quite  the  contrary,  we  must  ever  bear  in  mind  that  an 
infant  is  easily  fatigued,  irritated  and  indisposed,  and  hence  should 
not  be  overtaxed  even  by  the  simplest  methods  of  training.  This  holds 
true  also  of  older  children,  for  many  a  supposedly  nervous,  naughty, 
intractable,  listless  or  morose  child,  on  careful  inquiry,  is  found  to  be 
suffering  from  the  effects  of  overtaxation  of  its  mind  by  injudicious 
entertaining,  or  training  and  education. 

On  a  previous  occasion  attention  has  been  directed  to  the  serious 
consequences,  in  the  way  of  mental  affections,  not  rarely  following 
febrile  diseases  of  childhood.  Here  also  it  is  in  the  physician's  province 
to  educate  the  public  that  measles  is  not  a  "children's  ailment  that 
every  child  must  go  through,"  that  whooping  cough  is  not  "harmless 
and  makes  children  fat  thereafter,"  and  that  "scarlet  rashes"  are  "of 
no  consequence  and  the  result  of  a  spoiled  stomach  or  teething."  And 
the  sooner  the  people  will  appreciate  that  grave  danger  lurks  even  in 
the  most  benignly  appearing  attacks  of  infectious  diseases,  the  sooner 
wall  the  mental  deficiencies  arising  from  this  cause  dwindle  down  to 
insignificance. 


AMENTIA  737 

Active  Treatment 

We  can  now  pass  on  to  the  treatment  of  amentia,  and  since  this 
chapter  is  intended  for  the  discussion  of  mental  deficiencies  in  infants 
and  children  under  school  age  only,  we  propose  to  speak  only  of  thera- 
peutic measures,  (hygienic,  pedagogic,  physical,  medicinal  and  surgi- 
cal) as  they  are  applicable  chiefly  in  the  management  of  aments  under 
five  years  of  age. 

Hygiene 

An  ample  supply  of  fresh  air  and  good  food,  bodily  cleanliness  and 
proper  clothing  are  essential  prerequisites;  in  many  respects  more  so 
in  the  care  of  aments  than  in  normal  children.  Owing  to  the  tendency 
of  mentally  deficient  children  to  contract  tuberculosis  and  the  fre- 
quency of  respiratory  embarrassment  as  a  result  of  nasal  disease  or 
deformity,  they  should  be  kept  outdoors  most  of  the  day  and  in 
thoroughly  ventilated  rooms  during  the  night  or  inclemency  of  the 
weather.  This  fact  should  strongly  be  impressed  upon  those  who  take 
care  of  these  children,  since  most  mothers  are  apt  to  mistake  the  cause 
for  the  effect  and  attribute  the  difficult  breathing  and  nasopharyngeal 
catarrh  to  "catching  cold"  in  the  street. 

Several  precautions  have  to  be  taken  in  feeding  mentally  backward 
infants.  Some  of  them  owing  to  their  voracious  appetite  and  lack  of 
prehension  of  the  sense  of  heat  or  proportion,  are  apt  either  to  burn 
their  mouths  with  hot  food  or  swallow  big  morsels,  and  thus  perma- 
nently impair  their  powers  of  digestion.  In  the  majority  of  cases, 
therefore,  it  is  required  to  prepare  and  subdivide  the  food  properly, 
just  ready  for  consumption.  Others  again  because  of  an  imperfect 
sense  of  taste  and  inability  to  manipulate  the  tongue,  often  refuse 
food,  especially  solids,  and  have  to  be  fed  with  small  quantities  of 
food  at  frequent  intervals.  Owing  to  nasal  obstruction,  either  as  the 
result  of  adenoids,  nasal  deformities,  or  general  debility,  some  con- 
genital idiots  experience  difficulty  to  nurse  at  the  breast ;  hence,  it  is 
often  necessary  to  pump  off  the  breast  milk  and  to  feed  the  baby 
either  through  a  bottle  and  small  nipple  or  by  means  of  a  spoon.  As 
soon  as  possible,  let  us  say  from  the  eighth  month  on,  mentally  back- 
ward infants  should  be  put  on  a  mixed  diet,  in  order  to  prevent 
rachitis  or  scurvy.  We  usuallj^  begin  with  small  quantities  of  fresh 
fruit  juice,  beef  juice,  strained  vegetable  soups,  coddled  eggs,  cereals 
with  milk,  stewed  fruit  and  vegetable  puree,  gradually  increasing  the 
quantity  of  food  as  they  get  older,  so  that  at  the  age  of  three  or  four 
years  they  can  be  put  on  the  following  dietary: 


738  .  DISEASES   OF   CHILDREN 

On  rising  in  the  morning,  4  ounces  of  milk,  preferably  boiled. 

One  hour  later,  about  8  a.m.,  %  ounce  of  orange,  pineapple,  or  grapefruit  juice; 
4  to  6  ounces  of  well-cooked  cereal  in  milk  and  a  little  butter,  e.g.,  oatmeal,  farina, 
sago,  rice,  tapioca,  cream  of  wheat  or  arrowroot;  milk  toast,  and  a  coddled  or 
poached  egg. 

At  about  12  m.,  4  ounces  of  broth  with  some  cereal  or  toasted  bread;  2  ounces  of 
vegetables  (potatoes,  carrots^  spinach,  cauliflower,  beans,  peas,  etc.)  well  cooked 
and  finely  mashed;  %  ounce  of  finely  chopped  scraped  beef,  chicken  or  lamb  chop, 
or  boiled  or  broiled  white  fish.  If  the  child  is  still  hungry  we  may  add  a  slice  or 
two  of  stale  bread  and  butter,  divided  into  small  pieces. 

At  4  p.m.  one  cup  of  boiled  milk  with  a  few  biscuits  with  jelly  or  butter;  or  a 
ripe  banana. 

At  6  p.m.,  one  coddled  egg,  bread  and  butter  or  jelly,  and  4  ounces  of  boiled 
milk;  or  cereal  pudding  or  custard,  bread  and  jam  or  treacle;  or  a  cup  of  cocoa 
with  toasted  bread  thrown  in  and  a  small  portion  of  stewed  fruit. 

Water  should  be  given  between  meals. 

Before  and  after  each  meal  the  child's  hands  and  face  should  be 
thoroughly  washed  as  a  routine  procedure,  which  may  aid  also  in 
teaching  the  child  cleanly  habits. 

The  training  of  cleanliness  is  very  essential  to  the  child's  future 
welfare,  since  it  not  only  serves  to  make  it  more  presentable  to  those 
coming  in  contact  with  it,  but,  which  is  by  far  more  important,  it 
acts  as  the  most  efficient  preventative  of  divers  local  and  constitu- 
tional infections.  In  addition  to  frequent  local  cleansing  of  the  body 
as  necessity  arises,  it  should  receive  a  tub  bath  daily,  preferably  in 
the  evening,  in  the  same  manner  as  normal  children.  Regardless  of 
the  mental  condition  of  the  child,  every  effort  should  be  made  to  train 
him  to  respond  to  Nature's  calls.  From  six  months  of  age  on  he 
should  be  put  on  a  nursery  chair  at  regular  intervals,  at  first  every 
two  hours  and  later  every  three  or  four  hours.  If  his  bowels  do  not 
move  spontaneously  after  he  has  been  sitting  on  the  chair  for  several 
minutes,  the  infant  should  be  trained  to  press  by  inserting  into  the 
rectum  a  small  soap  stick  or  glycerine  suppository.  After  persistent 
training  even  the  idiot  will  gradually  learn  to  understand  what  is 
expected  of  him,  when  placed  upon  the  nursery  chair,  and  in  time  he 
will  of  his  own  accord  announce  his  desire  to  urinate  or  defecate. 
Aments  more  so  than  normal  children,  should  receive  more  care  as 
regards  changing  of  diapers  and  keeping  the  mouth,  nose  and  eyes 
clean,  in  view  of  the  fact  that,  as  a  rule,  they  are  less  sensitive  to 
pain  and  annoyance,  and  hence  are  less  apt  to  complain  when  those 
portions  of  the  body  are  in  an  irritated  state.  Moreover,  special  at- 
tention should  be  paid  to  apparently  the  simplest  kinds  of  cutaneous 
eruptions  as  these  often  serve  as  portals  of  entry  to  systemic  infec- 
tions. 


AMENTIA  739 

Mentally  deficient  infants,  especially  if  delicate  and  thin,  should  be 
very  warmly  dressed.  They  may  suffer  greatly  from  the  effects  of 
cold  and  yet  fail  to  appreciate  it,  owing  to  dulness  of  sensibility. 
Chilblains  and  frost  bites  are  quite  common  among  them  and  general 
circulatory  disturbances  are  frequently  encountered,  especially  in 
Mongolians  and  cretins.  Flannel  and  silk  underwear  should  be  given 
preference  to  cotton  or  flannelette.  During  the  cold  season  special 
protection  should  be  accorded  to  the  hands,  feet  and  ears,  and  very 
delicate  infants  may  preferably  be  kept  indoors,  in  well  ventilated 
rooms,  particularly  if  they  show  a  marked  tendency  to  congestion  of 
the  nasopharyngeal  mucous  membrane. 

"Incentive"  Training,  and  Physical  Therapeutic  Measures 

The  main  object  of  systematic  training  in  amentia  is  to  render  the 
mentally  backward  child  capable  to  help  himself  in  the  care  of  his 
body,  to  look  out  for  his  health  and  comfort,  and  later  to  learn  some 
simple  occupation  to  earn  a  livelihood.  This  requires  first  of  all  the 
ability  to  exercise  the  voluntary  musculature.  Since  in  a  great  many 
aments  several  groups  of  muscles  are  either  atrophied  and  incapaci- 
tated from  disuse  or  actually  paralyzed,  we  must  endeavor  to  estab- 
lish or  reestablish  their  functions  by  passive  motion,  massage,  hydro- 
therapy, electricity  and  active  exercise.  These  procedures  must  be 
continued  uninterruptedly  daily  for  months  and  sometimes  for  several 
years,  notwithstanding  their  seeming  futility.  In  the  end  we  are 
usually  amply  rewarded  by  success  for  our  patience  and  perseverance. 
Even  in  the  paralytic  it  has  repeatedly  been  found  that  the  function 
of  the  diseased  cerebral  area  has  been  taken  up  by  the  corresponding 
healthy  structures  of  the  brain;  and  as  has  been  shown  by  Vitzow, 
Pfitzner,  Merk,  Cattani,  Klebs  and  others,  in  exceptional  cases  actual 
regeneration  of  nerve  tissue  occurs  where  its  injury  is  not  very  pro- 
nounced. The  physical  treatment  of  the  affected  limbs  should  begin 
as  soon  as  their  weakness  or  paralysis  has  been  determined  regardless 
of  whether  or  not  reaction  of  degeneration  has  supposedly  taken 
place.  For  it  is  by  far  safer  to  err  in  the  direction  of  overtreatment 
than  undertreatment.  Let  me  illustrate  this  point  by  a  case  under 
my  observation.  It  concerns  a  three-year-old  boy  who  received  severe 
cranial  injuries  during  instrumental  delivery.  The  abrasions  from 
the  blades  of  the  forceps  were  still  visible  six  weeks  after  birth,  when 
the  child  came  under  my  care.  There  was  at  the  time  distinct  paraly- 
sis of  the  face,  of  both  upper  extremities  and  of  the  right  leg.  A  few 
days  before,  the  baby  was  seen  by  a  noted  neurologist  who  thought 
there  was  no  hope  of  his  ever  recovering,  and  discouraged  further 


740  DISEASES   OF    CHILDREN 

treatment.  The  case  did  look  liopeless,  yet  the  parents  failed  to 
reason  as  disinterestedly  as  the  learned  doctor  did,  and  I  also  agreed 
with  them  that  the  baby  ought  to  ])e  given  a  chance  to  fight  for  his 
own.  The  facial  paralysis  proved  peripheral  in  character  and  the 
paralysis  of  the  left  arm  was  of  the  Duchenne-Erb  type ;  both  disap- 
peared under  massage,  electricity  and  patience,  while  the  right  hemi- 
plegia has  improved  so  much  that  the  boy  is  able  to  walk  about  with 
ease  and  to  participate  in  all  sorts  of  children's  games.  Moreover, 
his  mentality  seems  perfectly  normal.  I  may  add,  by  the  way,  that 
his  cranial  circumference  measures  about  22  inches,  and  by  its  shape 
and  consistency  gives  the  impression  of  a  macrocephalus  accompany- 
ing hypertrophy  of  the  brain. 

There  are  a  few  practical  points  to  keep  in  mind  in  the  application 
of  massage,  electricity  and  hydrotherapy.  The  massage  movements 
should  consist  of  stroking,  friction,  kneading,  light  pinching,  tapping 
and  rhythmic  vibration.  The  duration  of  each  treatment  should  vary 
from  a  few  minutes  in  the  beginning  up  to  a  quarter  of  an  hour  after 
the  child  has  become  used  to  the  manipulations.  This  should  be  fol- 
lowed by  passive  motion  of  a  few  minutes'  duration.  The  massage 
should  be  gentle,  preferably  by  means  of  talcum  powder,  since  it  al- 
lows the  hands  to  glide  smoothly  over  the  body  surface. 

Electricity  should  be  administered  from  ten  to  twenty  minutes  at  a 
sitting,  either  daily  or  every  other  day,  using  the  mildest  current  that 
will  cause  muscular  contraction  without  undue  pain.  The  galvanic 
and  faradic  currents,  alternated  with  the  sinusoidal,  answer  the  pur- 
pose well.  If  single  muscles  or  muscle  groups  are  affected,  the  sponge 
electrodes  are  to  be  applied  near  or  at  the  points  of  origin  and  inser- 
tion of  the  muscles,  while  if  whole  extremities  are  involved,  we  apply 
a  large  flat  sponge  electrode,  well  moistened  in  warm  salt  water,  on 
the  spine  and  stroke  the  affected  muscles  with  a  small  electrode. 

Hydrotherapy  is  particularly  useful  in  amentia  associated  with  mus- 
cular rigidity  and  general  cerebral  irritability.  A  warm  (98°  F.  to 
101°  F.)  tub  bath,  of  from  five  to  ten  minutes'  duration,  should  be 
given  once  or  twice  a  day,  and  while  the  child  is  in  the  tub  its  limbs 
should  be  gently  rubbed  with  a  rough  flannel  and  if  possible  extended 
and  moved  in  all  directions. 

Simultaneously  with  the  application  of  these  therapeutic  procedures, 
we  employ  systematic  training  of  the  voluntary  musculature  and  of  the 
special  senses,  in  order  to  foster  the  physical  and  mental  devel- 
opment of  the  backward  child.  In  pursuing  this  course  of  treatment 
we  must  as  closely  as  possible  follow  the  successive  steps  taken  by 
Nature  in  the  unfolding  of  the  human  intellectual  faculties,  and  avail 


AMENTIA  741 

ourselves  of  the  child's  natural  instincts  to  assist  us  in  our  efforts.  In 
our  study  of  the  normal  baby  we  have  noted  that  immediately  after 
birth  he  is  endowed  with  the  instinct  of  suckling,  or  '^fishing"  for 
food,  and  to  cry  when  hungrj-  or  thirsty.  This  instinct  is  as  strongly 
developed  in  the  idiot  as  in  the  normal  child.  Now,  then,  since  the 
struggle  for  food,  for  self-preservation,  forms  the  ever  and  every- 
where dominating  and  propelling  force  of  evolution  in  the  animal 
kingdom  of  the  entire  universe,  and  has  formed  the  most  vital  in- 
centive even  in  primitive  man  to  devise  ways  and  means  for  its 
sustenance  and  perpetuation,  I  believe  that  the  irresistible  force  to 
quench  thirst  and  to  appease  hunger  ought  to  be  sufficiently  power- 
ful to  awaken  even  the  total  idiot  from  his  mental  torpor,  and  to  in- 
duce him,  as  it  were,  to  struggle  for  his  existence.  Indeed,  the  longer 
I  practice  this  incentive  method  of  training  of  the  mentally  defective 
infant,  the  more  convinced  I  am  of  its  superiority  over  every  other 
method  of  training  in  vogue.  We  make  use  of  his  desire  for  food  to 
teach  him  how  to  look,  how  to  listen,  how  to  pay  attention,  how  to 
grasp,  how  to  imitate  personally  and  M'ith  objects,  how  to  walk  and 
how  to  talk — all  in  the  order  in  which  the  normal  baby  acquires 
these  faculties,  except,  of  course,  at  greatly  delayed  periods  as  com- 
pared with  the  age  of  the  normal  baby.  The  sooner  the  training  is 
begun,  the  more  promising  are  the  results,  principally  because  in 
amentia  of  long  standing  the  brain  cells  usually  entirely  lose  their 
regenerative  quality.  This  fact  should  strongly  be  impressed  upon 
the  unfortunate  parents  who  rarely  note  any  mental  deficiency  in 
their  infants,  and  if  they  do,  are  often  led  to  believe  that  they  will 
'^ outgrow  their  weakness  when  they  get  to  be  seven  years  old." 

As  amentia  is  very  readily  recognizable  in  an  infant  about  six 
months  of  age,  we  proceed  with  the  training  in  the  following  manner: 

1.  If  it  is  a  nursing  baby,  he  is  put  on  the  lap  facing  the  mother 
or  wet-nurse,  and,  after  exposing  the  breast,  the  baby's  hands  are 
brought  in  contact  with  it  and  manipulated  so  as  to  make  them  grasp 
it.  This  is  repeated  for  a  few  minutes  before  each  nursing.  We  next 
bring  the  baby  near  the  breast  nipple  and  squirt  a  little  milk  in  his 
mouth.  As  the  baby  puckers  his  lips  to  grasp  the  breast  nipple,  we 
promptly  pull  the  child  back,  so  as  to  force  him  to  struggle  to  get  a 
good  hold  of  it.  This  also  is  repeated  for  a  few  minutes.  If  it  is  a 
bottle  baby,  we  perform  the  same  maneuvers  with  the  bottle  and 
nipple.  As  he  gradually  learns  to  recognize  the  bottle,  Ave  next  en- 
deavor to  train  the  baby  to  follow  the  course  of  the  bottle  by  slowly 
moving  it  before  his  eyes  in  all  directions,  before  allowing  him  to  get 
hold  of  the  nipple  as  it  comes  near  his  mouth.     It  may  take  several 


742  DISEASES    OF    CHILDREN 

days,  weeks  or  even  months  to  accomplish  this  trick,  but  patience  and 
perseverance  are  the  keynote  to  success  in  the  training  of  the  men- 
tally defective. 

2.  After  the  baby  has  acquired  the  power  of  grasping  the  bottle, 
we  place  the  child  in  a  semirecumbent  posture  with  the  head  resting 
on  a  small  pillow,  put  the  bottle  in  his  hands,  and  as  he  is  about  to 
start  to  suck  the  nipple,  we  slowly  pull  the  bottle  backwards  and 
continue  to  do  so  while  the  child  is  making  every  effort  to  bring  the 
bottle  to  his  mouth,  and  by  hanging  on  to  the  bottle  lifts  himself 
from  the  recumbent  to  a  sitting  posture.  This  up-and  down-movement 
is  exceedingly  useful  to  strengthen  the  arm-  and  spinal  muscles  and 
to  train  the  child  to  raise  himself  from  a  recumbent  posture.  Of 
course,  these  exercises  must  be  continued  for  several  minutes  before 
each  feeding. 

3.  Like  normal  babies,  aments  also  should  receive  a  mixed  diet 
when  they  reach  eight  or  nine  months  of  age.  Most  of  them,  as  a 
rule,  can  be  readily  induced  to  take  eggs  and  fruit,  which  are  most 
excellent  bone  and  brain  builders.  We  hold  the  egg  in  front  of  him 
and  feed  him  with  a  spoon  at  short  intervals,  making  him  wait  for 
the  next  spoonful  until  he  shows  anxiety  to  get  it.  If  a  white  egg 
does  not  attract  his  attention,  we  color  it  red  or  blue,  and  move  it  in 
different  directions  to  teach  him  to  follow  objects.  Similarly,  hold  a 
red  apple  in  front  of  him,  scrape  some  of  it,  and  feed  him  at  short 
intervals;  bring  the  fruit  near  his  nose  and  let  him  learn  to  perceive 
its  odor.  Some  idiots  have  a  highly  sensitive  sense  of  smell,  and  by 
using  attractive  odors  as  a  bait,  they  can  be  induced  to  awaken  from 
their  apathy  and  to  respond  better  to  the  systematic  training.  Next, 
place  the  child  near  the  side  of  the  crib  and  put  his  hands  on  the 
upper  cross-bar,  and  while  you  hold  the  apple  at  a  short  distance 
above  his  head,  with  one  hand,  help  the  child  to  lift  himself  from  his 
position  with  the  other  hand ;  as  he  accomplishes  it,  let  him  have  some 
of  the  apple,  (orange  or  peppermint  stick),  and  let  him  go  through 
the  same  performances  again  and  again  to  earn  some  more  of  it. 

4.  By  means  of  a  rod  and  cord,  suspend  a  red  apple  or  orange  in 
front  of  the  baby,  and  let  it  hang  there  for  a  little  while.  If  he  re- 
mains passive,  bring  the  apple  near  him  and  let  him  grasp,  smell  and 
taste  it;  if  he  is  now  attracted  by  it,  swing  the  apple  to  and  fro  and 
encourage  him  to  follow  it  with  the  hands  and  grasp  it.  Repeat  the 
exercise  several  times  and  let  him  have  some  of  the  apple  for  each 
successful  effort.  Toys  may  be  used  instead  of  eatables  where  the 
child  shows  preference  for  the  former.    By  continuing  these  exercises 


AMENTIA  743 

the  child  gradually  gains  considerable  power  of  attention  and  muscu- 
lar coordination. 

5.  Aments  should  early  be  taught  to  feed  themselves.  Sit  him  in  a 
baby  chair,  if  need  be  well  supported  with  pillows,  and  place  the  food 
before  him.  Give  him  a  taste  of  it,  and  if  he  is  good  and  hungry,  he 
will  ''fish"  for  more.  In  this  event,  if  the  food  is  solid  (e.  g.,  a  zwie- 
back), put  it  in  his  hand  and  guide  him  repeatedly  to  bring  it  to  his 
mouth.  It  is  usually  a  very  difficult  task,  to  teach  mentally  deficient 
children  to  feed  themselves,  but  hunger  and  persistent  training  will 
accomplish  it  in  the  end. 

6.  To  teach  him  to  stand,  we  place  him  against  the  side  of  the  bed 
with  his  arms  crossing  the  top  bar,  and  feed  him  with  a  spoon  in  such 
a  manner  that  he  is  forced  to  raise  his  head  to  receive  the  food.  In 
the  beginning,  it  is  usually  required  to  support  his  back  to  keep  him 
from  falling.  As  he  learns  to  stand,  put  him  in  a  softly  padded  walker, 
the  top  of  which  snugly  surrounds  his  waist.  Keep  the  dish  of  food  in 
front  of  him,  give  him  a  mouthful  of  it  and  take  a  short  step  back- 
ward ;  let  him  follow  you  (which  in  the  beginning  may  call  for  your 
assistance) ;  give  him  another  mouthful  and  let  him  again  push  for- 
ward. Repeat  this  a  few  times  a  day,  at  first  only  for  a  very  short 
time,  in  order  not  to  tire  him.  A  doll  carriage  may  occasionally  suf- 
fice as  a  support  instead  of  a  walker,  especially  after  the  child  has 
partly  learned  to  walk,  and  only  needs  additional  exercise. 

7.  Gradually  train  him  to  walk  without  any  support.  This  is  best 
accomplished  first  by  standing  him  against  a  wall,  and  while  facing 
him,  let  him  grasp  one  of  your  index  fingers,  and  follow  you  while 
you  take  single  steps  backward.  Later  extend  to  him  a  cane  or  rod 
instead  of  your  fingers.  If  he  hesitates  to  follow  you,  use  some  fruit, 
sugar  or  candy  as  an  incentive,  which  you  hold  in  front  of  him  and 
reward  him  with  for  successful  efforts.  Or  put  his  food  on  a  low 
table,  direct  his  attention  to  it  and  lead  him  towards  it.  In  time  he 
will  go  after  his  food  without  being  led. 

8.  All  the  while  the  child  is  receiving  instructions  keep  on  telling  him 
what  you  are  doing  and  what  you  wish  him  to  do,  regardless  of 
whether  or  not  he  understands  you.  Gradually  he  will  learn  to 
understand  at  least  part  of  what  you  are  telling  him.  Use  single 
words  instead  of  sentences,  e.  g.,  eat,  drink,  walk,  etc.,  and  repeat  the 
words  in  a  firm  tone  of  voice,  in  order  to  make  a  lasting  impression 
upon  the  auditory  center. 

9.  After  he  has  learned  the  different  exercises,  you  can  begin  to 
interest  him  in  drills,  tricks,  and  games  as  practiced  in  modern  kin- 
dergartens.    Almost  all  mentally  deficient  children  are  charmed  by 


744  .      DISEASES   OF    CHILDREN 

music;  it  is  therefore  of  great  advantage  to  make  use  of  luirnionious 
strains  of  the  piano  to  arouse  the  dull  child  from  his  slum])er  and  to 
soothe  the  discordant  impulses  of  the  agitated  child.  Different  strains 
of  music  should  be  used  for  different  sets  of  actions,  in  order  to  train 
the  child's  auditory  apparatus  to  connect  the  particular  melody  with 
the  particular  act  he  is  to  perform ;  in  other  words,  one  and  the  same 
melody  with  his  meals,  another  one  M'hen  he  marches,  a  third  when 
he  plays  a  certain  game,  etc.  Music  should  be  emploj-ed  also  in 
training  him  to  speak.  Thus,  while  playing  the  piano  sit  the  child 
in  front  of  you,  attract  his  attention  to  your  mouth,  and,  with  a  tone 
of  voice  corresponding  to  the  strains  of  music,  keep  on  repeating 
single  syllables  or  words,  e.  g.,  ba-ba  for  one  melody,  la-la  for  another, 
ta-ta  for  a  third  and  so  forth,. gradually  lengthening  the  syllables  into 
whole  words.  In  speech,  as  in  other  exercises,  its  accomplishment  is 
often  facilitated  by  using  food  as  an  incentive,  i.  e.,  give  him  a  piece 
of  candy  every  time  he  makes  an  earnest  effort  to  pronounce  certain 
syllables  or  words. 

10.  Imitation  is  the  mother  of  experience.  Teach  him  to  imitate 
your  personal  movements,  such  as  kneeling,  sitting,  standing,  opening 
and  closing  of  the  mouth  or  hand,  throwing  a  ball  or  catching  it,  and 
similar  exercises. 

11.  Sit  the  child  near  a  table  facing  you ;  spread  out  in  front  of 
him  some  candy  or  some  other  eatable  he  is  fond  of,  and  let  him  taste 
some  of  it.  If  he  likes  it,  he  will  surely  look  for  some  more  of  it. 
Now  cover  the  remaining  pieces  of  candy  with  a  strip  of  paper,  leav- 
ing part  of  it  exposed.  If  he  shows  ability  to  remove  the  paper  and 
to  help  himself  to  the  candy,  put  the  latter  in  a  little  box,  first  with- 
out a  cover  and  then  with  a  transparent  cover.  Now  teach  him  to  un- 
cover the  box,  and,  if  he  succeeds  doing  it,  reward  him  with  a  piece 
of  candy.  Next  put  the  candy  in  a  more  complicated  contrivance,  and 
the  more  ability  he  shows  to  help  himself,  the  more  difficult  should  it 
be  made  for  him  to  find  the  thing  he  is  looking  for.  By  repeated 
training  he  will  gradually  learn  to  help  himself  in  many  other  re- 
spects. 

12.  Place  the  child  in  front  of  a  step  ladder  and  put  the  candy  on 
one  of  the  rungs  and  encourage  him  to  reach  for  it.  Of  course,  at 
first  he  will  need  your  help.  As  he  ascends  the  ladder,  hand  him  a 
piece  of  candy.  Eepeat  this  maneuver  again  and  again,  and  as  he 
succeeds  in  getting  there,  elevate  the  box  to  a  higher  level.  In  a 
similar  manner  reverse  the  performance,  i.  e.,  make  him  descend  in 
order  to  reach  the  box.     As  he  learns  to  accomplish  this  with  ease, 


AMENTIA  745 

teach  him  to  climb  stairs,  first  by  supporting  liims?lf  with  tlie  hands 
and  later  by  doing  it  without  support. 

The  performances,  of  course,  can  be  multiplied  almost  ad  infinitum. 
But  there  are  two  essential  ideas  ever  to  be  kept  in  view  in  the  train- 
ing of  aments — namely,  first,  no  coercion  or  force  is  to  be  applied ; 
second,  no  time  and  energy  should  be  wasted  on  exercises  which  are 
not  absolutely  indispensable  to  his  welfare.  If  we  succeed  in  training 
a  deficient  child  under  five  years  of  age,  to  be  clean,  to  feed  himself, 
to  walk,  to  understand  words  spoken  to  him  and,  possibly,  to  make 
himself  understood,  even  if  only  by  single  words,  enough  indeed  will 
have  been  accomplished.  By  opening  up  the  avenues  of  approach 
to  the  dormant,  deficient  infantile  brain,  the  brain  itself  will  spon- 
taneously evolve  its  resourcefulness,  round  out  the  experience,  and 
receive  new'  impressions. 

In  suggesting  the  aforementioned  exercises  I  presume,  of  course, 
that  we  are  not  dealing  with  total  idiocy  accompanying  extreme  de- 
grees of  hydrocephalus,  microcephalus,  diplegia,  etc.,  or  amaurotic 
family  idiocy.  In  these  cases  no  amount  of  conscientious  training 
ever  will  bear  fruit  in  restoring  degenerated  brain  tissues  to  normal 
function.  Moreover,  the  span  of  life  of  these  unfortunates  measures 
but  a  few  years.  On  the  other  hand,  when  confronted  by  a  mentally 
deficient  child  who  is  free  from  gross  cerebral  lesions  and  shows  some 
response  to  outside  influences — for  example,  a  child  of  two  years  re- 
sponds to  the  mental  tests  for  a  normal  baby  of  six  months — pains- 
taking and  persistent  training  will  most  assuredly  bring  forth  very 
gratifying  results,  even  though  in  the  beginning  nothing  but  failure 
will  seem  to  crown  our  efforts.  The  late  Edouard  Seguin,  one  of  the 
early  pioneers  in  the  training  of  mental  defectives,  when  once  asked 
why  he  kept  on  repeating  the  same  movements  a  hundred  times  a 
day,  replied  because  the  child  does  not  make  them  right  ninety-nine 
times.  This  was  the  secret  of  his  phenomenal  success.  And  it  is 
essential  to  impress  upon  the  parents  that  unless  they  themselves  are 
endowed  with  an  ample  supply  of  patience,  tact  and  perseverance, 
to  keep  on  teaching  their  child  the  same  thing  for  days,  weeks  and 
months,  this  work  should  be  intrusted  to  some  one  who  possesses  these 
qualities,  or  no  great  achievements  need  be  expected. 

Finally,  in  training  the  w^eak-minded  it  is  well  to  remember  that 
the  unfortunate  baby  is  not  to  be  blamed  for  his  failure  promptly  to 
apprehend  and  to  copy  the  apparently  simplest  rudiments  of  thought 
and  action'.  He  is  heartily  to  be  pitied  rather  than  disdained ;  and  as 
the  great  majority  of  aments  are  providentially  blessed  with  a  con- 


746  .DISEASES   OF    CHILDREN 

tent  and  joyful  disposition,  we  might  as  Avell  refrain  from  shattering 
their  peace  of  mind  by  undue  harshness  or  rough  handling. 

Medicinal  Treatment 

When  discussing  cretinism,  attention  has  been  directed  to  the  mar- 
velous physical  and  mental  transformation  occurring  on  the  adminis- 
tration of  thyroid  extract  in  amentia  due  to  thyroid  insufficiency. 
Wherever  the  cause  of  amentia  was  uncertain,  I  made  it  a  rule,  to 
give  the  child  the  benefit  of  a  few  weeks'  thyroid  treatment  in  order 
to  determine,  whether  or  not  the  thyroid  was  at  fault.  Moreover,  for 
the  last  two  or  three  years  I  believe  to  have  found  it  of  advantage  to 
supplement  the  thyroid  medication  bv  the  extracts  of  parathyroid, 
thymus,  and  pineal  and  pituitary  glands,  in  accordance  with  the  es- 
tablished fact  that  whenever  the  thyroid  is  affected,  the  functions  of 
the  other  glands  are  also  more  or  less  impaired.  In  one  case,  particu- 
larly, the  effect  of  the  combined  glandular  medication  was  singularly 
striking.  It  concerned  a  six-year-old  boy  who  for  three  years  had 
been  treated  with  thyroid  extract  by  several  eminent  clinicians. 
When  I  first  saw  him  he  measured  35  inches  in  height  and  weighed 
41  pounds.  His  voice  was  husky,  and  he  could  pronounce  but  a  few 
words  in  a  draggy,  staccato  sort  of  fashion.  His  face  and  lips  were 
edematous,  and  his  tongue  protruded  slightly.  When  led  by  the 
hand  he  was  able  leisurely  and  awkwardly  to  move  along,  but  if  left 
alone  he  was  barely  able  to  take  a  few  steps  without  stumbling.  I 
put  him  on  the  aforementioned  glandular  extract  compound,  and  he 
gained  II/2  inches  in  height,  3  pounds  in  weight,  and  a  great  deal  in 
intelligence.  He  became  so  active  that  the  mother  experienced  con- 
siderable difficulty  to  "restrain  him  from  following  the  boys  in  the 
gutter."  As,  until  he  came  under  my  observation,  he  had  regularly 
been  receiving  from  2  to  5  grains  of  thyroid  extract  daily  without 
appreciable  benefit,  I  could  not  help  but  believe  that  the  marked  im- 
provement in  his  condition  was  due  solely  to  the  addition  of  the  para- 
thyroid, thymus,  pineal  and  pituitary  extracts.  The  mode  of  ad- 
ministration of  the  glandular  extracts  varies  somewhat  with  the  age 
of  the  child  and  the  degree  and  duration  of  the  affection.  In  con- 
genital cretinism  I  order  1  grain  of  thyroid  powder  twice  a  day,  to  a 
bottle-fed  baby,  and  only  half  the  quantity  to  a  breast-fed  infant, 
having  observed  that  the  latter  develops  the  manifestations  of  cretin- 
ism more  slowly  than  the  former,  owing  probably  to  the  fact  that  the 
breast  baby  in  the  first  few  months  of  life  receives  some  thyroid 
through  the  mother's  milk.  If  the  case  fails  to  show  improvement  in 
about    four    weeks,    I    begin    to    alternate    with    i^    grain    each    of 


AMENTIA  747 

parathyroid,  thymus,  pineal  and  pituitary  extract.  This  represents 
the  usual  dosage  for  an  infant  up  to  one  year  of  age.  Older  children 
should  receive  i/^  grain  of  the  thyroid  powder  and  1/4  grain  of  each 
of  the  other  glandular  substances  for  every  additional  year  of  their 
respective  ages  up  to  five  years.  The  dosage  in  tablet-form  is  about 
twice  as  large  as  that  of  the  powder.  After  considerable  improve- 
ment has  taken  place  in  the  child's  general  development,  the  dose  of 
the  thyroid  or  the  compound  should  gradually  be  reduced  to  once  a  day, 
once  every  alternate  day,  and  once  every  third  day.  Where  organo- 
therapy gives  rise  to  cardiac  palpitation,  undue  restlessness,  or  gas- 
tric irritability,  the  treatment  should  temporarily  be  suspended  until 
the  toxic  symptoms  have  disappeared,  when  the  medication  should 
be  resumed  in  smaller  quantities,  and  gradually  increased. 

There  are  several  other  medicinal  preparations  which  have  to  be 
resorted  to  in  the  management  of  the  different  forms  of  amentia.  Re- 
gardless of  cause,  it  is  often  judicious  to  place  an  ament  on  a  thorough 
antisyphilitic  treatment,  more  especially,  of  course,  when  the  Wasser- 
mann  reaction  is  positive  or  there  are  reasons  to  suspect  syphilis 
either  from  the  history  of  the  case  or  appearance  of  the  patient. 
Opinions  are  still  at  variance  as  regards  the  advisability  of  employ- 
ing neosalvarsan  in  the  treatment  of  syphilitic  amentia  in  children, 
and  I  am  inclined  to  give  preference  to  the  mixed  iodide  and  mercury 
treatment,  unless  there  be  special  need  for  hasty  action,  e.  g.,  syphil- 
itic hydrocephalus  with  marked  intracranial  pressure.  If  neosal- 
varsan is  indicated  it  should  be  administered  either  intravenously  or 
intramuscularly.  The  usual  dose  and  mode  of  administration  is  fully 
given  when  discussing  the  treatment  of  syphilis  (see  p.  494).  The 
effect  of  the  neosalvarsan  should  be  controlled  by  the  Wassermann 
reaction,  a  second  dose  being  administered  after  two  weeks  if  necessity 
arises. 

The  iodides  are  indicated  even  in  the  absence  of  a  syphilitic  taint, 
acting  as  they  do  as  powerful  alteratives  and  eliminants  of  divers  sys- 
temic poisons.  One  grain  of  the  sodium  iodide,  twice  daily,  for  every 
year  of  the  child's  age,  is  ample  for  ordinary  purposes.  The  syrup 
iodide  of  iron  in  10  to  20  drop  doses  may  be  alternated  with  the  sodium 
iodide,  or  some  of  the  newer  iodide  preparations  may  be  used  instead. 
To  obtain  results  the  iodide  should  be  continued  for  several  months, 
with  occasional  intermissions  of  short  duration,  in  order  to  avoid  gastric 
irritation.  It  is  often  found  very  beneficial  to  combine  the  syrup  iodide 
of  iron  with  cod  liver  oil  and  the  syrup  of  lime  hypophosphites,  more 
especially  ^^here  rachitis  complicates  the  amentia.  General  tonics  and 
appetizers  are  almost  always  indicated,  for  we  hardly  could  make  proper 


748  DISEASES   OF    CHILDREN 

use  of  our  incentive  method  of  training,  when  the  incentive,  hunger,  is 
lacking.  Small  doses  of  the  tincture  of  nux  vomica  and  cinchona  com- 
pound, in  orange  syrup,  before  meals,  and  dilute  hydrochloric  acid  and 
essence  of  pepsin  after  meals,  act  exceedingly  v^^ell  both  as  tonics  and 
digestants  and  should  be  prescribed  as  necessity  arises.  In  paralysis  or 
general  muscular  debility  it  is  often  advisable  to  administer  strychnine 
by  mouth  or  even  hypodermically.  One-three-hundredth  of  a  grain 
for  every  year  of  the  child's  age  up  to  five  years  will  ordinarily  suffice 
in  cases  of  moderate  severity.  The  dose  may  be  repeated  twice  or  three 
times  a  day.  Sometimes  sedatives  are  indicated,  and  I  have  found  that 
small,  frequently  repeated  doses  of  codeine,  dionin  or  heroin,  act  very 
much  more  promptly  in  relieving  attacks  of  twitching,  extreme  restless- 
ness and  insomnia,  than  the  bromides  or  other  hypnotics.  Of  course, 
in  epilepsy,  the  bromides  or  luminal  are  indispensable,  and  instead  of,  as 
is  usually  advised,  giving  small,  gradually  increased  quantities  of  bro- 
mide, I  have  found  it  very  much  more  profitable  to  start  with  large  doses, 
and  to  reduce  them,  after  the  periodic  attacks  have  been  arrested.  Thus, 
for  every  year  of  the  child 's  age  I  give  1  grain  each  of  potassium,  sodium 
and  strontium  bromide,  three  times  a  day,  and  continue  the  same  until 
I  have  succeeded  in  arresting  the  usual  fit  for  several  months.  Then  the 
dosage  may  slowly  be  reduced  if  it  is  found  that  the  child  is  too  drowsy 
or  signs  of  bromism  make  their  appearance.  I  prefer  to  combine  the 
bromides  with  small  doses  of  Fowler's  solution  and  the  mixture  of  rhu- 
barb and  soda,  the  arsenic  seemingly  preventing  bromism  while  at  the 
same  time  acting  as  a  nerve  tonic,  and  the  rhubarb  and  soda  serving  to 
subdue  the  undue  gastric  irritation.  In  habitual  constipation  which  is 
the  rule  in  mentally  deficient  babies,  i/^  grain  of  phenolphthalein  or  10 
drops  of  aromatic  fluid  extract  of  cascara  sagrada,  for  every  year  of  the 
child's  age,  or  liquid  petrolatum  in  teaspoonful  doses  will  be  found 
efficient,  particularly  if  the  movement  be  started  with  a  small  injection 
of  warm  soap  water  or  glycerine  suppository.  In  very  young  infants 
milk  of  magnesia  (1  or  2  teaspoonfuls,  best  mixed  with  the  entire  24 
hours'  quantity  of  milk)  usually  answers  the  purpose.  Special  atten- 
tion should  be  paid  to  the  nasopharynx.  Where  adenoids  exist  and 
greatly  interfere  with  respiration,  they  should  be  promptly  removed, 
otherwise  they  can  be  kept  from  doing  much  harm  by  keeping  the  naso- 
pharynx clean  with  Dobell's  solution  and  adrenalin  (1:1000),  equal 
parts,  and  the  instillation  into  each  nostril  of  a  few  drops  of  a  10  per 
cent  solution  of  argyrol,  solargentum,  or  the  like,  twice  a  week,  until  the 
inflammation  and  hypertrophy  of  the  adenoid  tissue  has  considerably 
subsided.  Intercurrent  diseases,  of  course,  must  be  treated  according 
to  indications  in  the  same  manner  in  aments  as  in  normal  children,  ex- 


AMENTIA  749 

cept  that  greater  attention  must  be  paid  to  the  prevention  of  passive, 
hypostatic  pneumonia,  and  even  to  trifling  ailments  which  ordinarily 
are  entirely  free  from  complications  in  normally  developed  children. 

Surgical  Treatment 

Surgery  as  an  aid  in  the  cure  of  idiocy  and  the  allied  mental  defi- 
ciencies has  been  resorted  to  especially  during  the  last  two  decades. 
The  results  obtained,  however,  are  far  from  being  satisfactory,  except 
in  cases  of  paral^'tic  amentia  due  to  cerebral  compression,  where  early 
decompression  has  not  rarely  brought  about  complete  regeneration  of 
the  brain  tissues  involved  and  restitutio  ad  integrum.  Harvey  Gushing 
has  performed  quite  a  number  of  craniectomies  on  the  newborn  to  re- 
lieve cerebral  compression  resulting  from  intracranial  hemorrhage 
during  birth  (which,  as  previously  mentioned,  forms  the  cause  of 
amentia  in  about  30  per  cent  of  the  cases  on  record),  and  is  of  the 
opinion  that  with  proper  regard  of  hemostasis  and  careful  avoidance 
of  undue  exposure,  the  newborn  will  stand  a  cranial  operation  well, 
its  life  will  often  be  saved,  and  in  many  instances  develop  normally. 
Roswell  Park  maintained  that  where  a  reasonable  integrity  of  brain 
structure  can  be  assumed,  there  was  no  reason  why  craniectomy  or  de- 
compression should  not  be  given  an  opportunity  in  imbecility  and 
psychic  disturbances,  in  order  to  relieve  pressure  and  permit  more 
normal  development.  And  William  Sharpe  and  H.  F.  Farrell  claim* 
very  good  results  from  cranial  decompression  in  cases  of  spastic  pa- 
ralysis (with  mental  deficiency)  of  hemiplegic,  paraplegic,  and  di- 
plegic  type  with  a  definite  history  of  difficult  labor  with,  or  without 
the  use  of  instruments,  in  which  on  ophthalmoscopic  examination  signs 
of  intracranial  pressure  are  shown  in  the  dilated  retinal  veins,  and  a> 
blurring  and  haziness  of  the  optic  discs,  especially  of  their  nasal  halves. 
In  these  cases  they  perform  a  large,  right  subtemporal  decompression, 
and  if  the  intracranial  pressure  remains  high,  they  perform  a  left  sub- 
temporal decompression  the  following  month.  The  after-treatment 
which  is  of  very  great  importance,  consists  in  the  correction  of  de- 
formities by  tendon  lengthening  and  stretching  of  the  contracted 
muscles :  the  maintenance  of  the  corrected  positions  by  the  employment 
of  especially  adapted  and  properly  fitting  braces,  and  skilled  massage 
in  conjunction  with  short  applications  of  galvanism  and  faradism.  A 
careful,  systematic  course  of  muscle  training  is  carried  out  daily. 
Sharpe  and  Farrell  claim  marked  improvement  not  only  in  the  spas- 
ticity but  in  the  mental  condition  of  the  patients  as  well,  so  much  so 


•In   several   cases  under  observation   the   results  proved   negative. 


750  DISEASES   OF    CHILDREN 

that  they  are  able  "to  receive  the  cooperation  of  tlie  patient  in  the 
carrying  ont  of  tlie  after-treatment."  Of  course,  the  earlier,  the  de- 
compression is  performed  the  greater  the  opportunity  and  facility  for 
the  compressed  brain  structures  to  adjust  themselves  in  their  normal 
relations  and  to  regain  their  normal  functions. 

As  has  already  been  started  the  results  from  operative  interference 
in  the  other  forms  of  amentia  are,  to  say  the  least,  but  temporary. 
Lannelogue's  craniectomy  for  the  relief  of  microcephalus,  which  at 
first  was  hailed  as  a  great  success,  soon  proved  a  total  failure  and  has 
rightly  been  abandoned  even  by  its  most  enthusiastic  exponents.  Sev- 
eral operations  have  recently  been  proposed  for  the  cure  of  hydro- 
cephalus, but  it  is  too  early  to  arrive  at  correct  conclusions  regarding 
the  improvement  in  the  child's  mentality  and  its  permanency.  Of  these 
operations  I  may  mention  G.  Anton's  efforts  to  relieve  intracranial 
pressure  by  puncture  of  the  corpus  callosum,  and  Irving  S.  Haynes' 
method  of  treating  hydrocephalus  by  cisterna-sinus  drainage. 

In  recommending  operative  interference  for  the  relief  of  congenital 
or  acquired  physical  defects  complicating  amentia  and  for  the  eventual 
restoration  to  normal  mentality,  considerable  conservatism,  of  course, 
should  be  exercised  in  the  proper  selection  of  the  cases.  But,  when- 
ever in  our  judgment  the  case  in  question  is  entirely  hopeless  if  left 
alone,  and  there  is  the  remotest  chance,  through  surgical  interference 
to  relieve  the  idiot  of  his  lifelong  misery,  we  should  not  at  all  hesitate 
to  recommend  surgical  treatment,  notwithstanding  the  accompanying 
appalling  mortality.  However,  before  resorting  to  surgical  interven- 
tion, the  mental  defective  should  for  a  reasonable  time  be  given  the 
benefit  of  some  of  the  other  therapeutic  measures  here  suggested. 

Prognosis 

Do  what  you  will,  even  under  most  scrupulous  application  of  all  of 
the  aforementioned  preventive  and  curative  measures,  amentia,  either 
of  prenatal,  natal,  or  postnatal  origin,  will  persist  and  exist  as  long  as 
man  will  inhabit  this  world.  Fortunately  the  majority  of  cases  of 
genuine  congenital  idiots  are  usually  short  lived.  This  is  true  espe- 
cially of  the  congenital  hydrocephalic,  paralytic  (associated  with  poren- 
cephaly and  cerebral  sclerosis),  Mongolian  with  congenital  heart  dis- 
ease, and  the  amaurotic.  The  great  majority  of  them  succumb  during 
early  infancy  or  childhood,  either  to  general  debility  or  to  intercurrent 
diseases,  more  particularly  pneumonia  and  tuberculosis.  The  pneu- 
monia is  usually  of  the  hypostatic  variety  that  readily  supervenes 
after  trifling  ailments  which  in  any  way  tend  to  depress  the  vitality 
of  these  weaklings.     The  prevalence  of  tuberculosis  among  them  can 


AMENTIA  7ol 

COL  ,~^-  ^-  - 
often  be  traced  to  an  liereditary  dispositioii,jSupepinduced  by  the  evei- 
present  nasopharyngitis  and  adenoids,  or  to  direct  infection  of  the 
alimentary  or  respiratory  tract  as  a  resnlt  of  the  extremely  unhyj^ienic 
habits  of  the  majority  of  low  grade  aments.  As  is  well  known,  idiots 
delight  in  rolling  in  filth  and  chewing  on  anything  and  everything 
picked  from  dirty  floors  and  streets,  and  it  is  quite  reasonable  to  sup- 
pose that  these  things  harbor  a  multitude  of  pathogenic  microorgan- 
isms, the  tubercle  bacillus  among  them.  On  rare  occasions  we  meet 
with  aments  of  very  robust  constitution,  who  are  not  susceptible  to  the 
ordinary  children's  diseases,  and  often,  almost  for  spite,  surmount 
violent  attacks  of  exanthemata,  gastroenteritis  and  the  like,  even  if 
left  alone  without  proper  hygienic  care,  suitable  feeding  or  medication. 
This  is  often  true  of  the  microcephalic  idiot  with  the  miniature  brain 
and  head  (see  p.  707),  and  the  postnatal  cretin. 

The  mortality  in  feeble-mindedness  of  postnatal  origin,  more  espe- 
cially in  children  who  receive  good  care  and  treatment,  as  a  rule,  is 
not  much  higher  than  in  normal  children,  provided  they  remain  free 
from  convulsive  seizures  and  are  able  to  be  around  and  about.  As 
regards  the  future  mental  progress  of  aments,  each  case  must  be 
judged  individually.  As  a  rule,  however,  mentally  deficient  children 
who  at  about  three  years  of  age  are  able  to  make  more  or  less  free 
use  of  their  extremities,  in  the  course  of  time  are  amenable  to  proper 
training.  Some  of  them  as  they  grow  older  can  be  made  useful  by 
teaching  them  light  outdoor  occupations,  such  as  gardening,  or  to 
assist  in  farming,  others  by  learning  to  help  along  in  different  trades, 
e.  g.,  basket  making,  carpet  laying,  carpentry,  and  others  again  by  do- 
ing errands,  etc.  Under  these  circumstances,  mpre  particularly,  since 
errors  in  the  diagnosis  of  the  exact  type  of  amentia  dealt  with  are  not 
at  all  uncommon  even  with  the  most  experienced  observers,  it  is  hardly 
just  or  expedient  to  declare  a  case  of  feeble-mindedness  unimprovable 
without  giving  it  a  fair  test  by  way  of  phj'sical  and  mental  training, 
or,  possibly  medical  or  surgical  treatment,  whenever  there  is  reason 
to  believe  that  these  therapeutic  measures  might  prove  of  some  bene- 
fit to  the  child,  or  at  least  will  do  no  harm. 

AMENTIA  IN  OLDER  CHILDREN 

Epileptic  Idiocy 

In  discussing  epilepsy  (see  p.  651)  attention  has  been  called  to  the 
severe  mental  impairment  following  and  often  accompanying  recur- 
rent epilep.tic  attacks.  In  a  great  many  cases  the  fits  and  the  idiocy 
are  based  upon  the  same  pathologic  condition  of  the  brain.     G.  H. 


nO  vr.Ar.eiJ 


Oll-i 


DISEASES   OF   CHILDREN 


752 

TAMO'Tci 

^ -S^yage,  reraarl?s,  ^hat:-th|ft  lepileptic  idiot  is  the  drollest  inlial)itant  of 

the  idiot  asylum.    He  is  often  wild,  untraetable,  and  irritable,  many  of 

the  symptoms  resemhlin^  those  of  ordinary  insanity.    The  management 

of  epileptic  idiocy  is  the  same  as  in  epilepsy  {q.  v.).      As  the  condition 

is  practically  hopeless,  there  need  be  less  conservatism  in  advocating 

operative  interference. 

Imbecility 

Imbecility  is  closely  related  to  idiocy,  and  is  based  upon  some  in- 
herent mental  privation  which  no  amount  of  education  can  entirely 
overcome.  It  may  be  the  result  either  of  congenital  or  acquired  struc- 
tural cerebral  derangement  consecutive  to  febrile  affections  or  endocrine 


Fig.  226. — Feeble-mindedncss  in  a  boy  eight  years  old  following  an  attack  of 
encephalitis;  he  is  suffering  also  from  slight  left  hemiplegia.  His  mental  age  is 
that  of  a  boy  four  years  old, 

disturbances.  The  condition  is  usually  not  detected  until  the  child  goes 
to  school,  when  it  is  found  that  as  compared  with  the  normal  pupil 
he  is  backward  in  understanding  and  reasoning,  though  he  may  be 
singularly  developed  in  special  directions,  e.  g.,  memory,  mechanical 
aptitude.     Further  observation  reveals   also  that  the   imbecile   is  ex- 


AMENTIA  753 

ceedingly  emotional,  easily  irritated  and  appeased  with  difificulty,  shows 
an  irresistible  passion  to  lie,  steal  and  play  truant,  and  that  long  before 
maturity  his  sexual  inclinations  are  in  the  highest  state  of  depravity. 
His  moral  decrepitude  increases  from  year  to  year,  and  may  range 
from  theft,  arson  and  rape  to  homicide  and  suicide. 

Imbeciles  should  be  placed  under  the  control  of  experienced  peda- 
gogues, preferably  in  some  lonely  country  place. 

BiNET-SiMON  Test  of  Mental  Development* 

It  is  now  possible  by  means  of  this  scale  to  determine  fairly  well 
the  mental  age  of  children.  There  will  be  much  less  indefiniteness 
regarding  the  terms  used  in  designating  the  types  of  feeble-mindedness. 

Thus,  the  term  "idiot,"  which  is  technically  restricted  to  those  who 
cannot  talk,  corresponds  to  the  mental  age  of  one  and  two  years. 

The  term  "imbecile,"  which  includes  persons  who  understand 
spoken  language  and  talk  with  varying  degrees  of  fluency,  corre- 
sponds to  the  mental  age  of  three,  four,  five,  six,  and  seven  years. 

The  "moron"  is  one  who,  in  addition  to  using  spoken  language,  is 
capable  of  learning  to  read  and  write,  and  he  corresponds  to  the 
mental  age  of  eight,  nine,  ten,  and  eleven  years. 

The  feeble-minded  are  persons  who  include  all  three  groups  and 
hence  correspond  to  the  mental  age  of  from  one  to  twelve  years.  A 
person  having  the  mental  age  of  twelve  may  be  retarded,  but  is  not 
feeble-minded,  and  technically  the  retarded  would  be  persons  who 
have  the  mental  age  of  twelve  to  fifteen  years  and  who  do  not  get 
beyond  it. 

Mental  Age  5  Years t 

Place  two  boxes  weighing  14  ^nd  V2  ounce  respectively  on  the  table 
before  the  child,  leaving  a  space  of  2  inches  between  them,  and  saj^ 
"You  see  these  two  boxes?  Tell  me  which  is  the  heavier.  Repeat  using 
boxes  weighing  I/2  ^^icl  %  of  an  ounce,  and  repeat  again,  using  first  pair. 

Place  an  oblong  card  on  the  table  before  the  child  and  place  also, 
nearer  to  the  child,  two  triangular  cards  formed  by  cutting  another 
card  like  the  first  one  in  two,  along  a  diagonal.  Place  these  two  tri- 
angular cards  in  such  position  that  their  hypothenuses  form  a  right  angle 
one  with  the  other,  then  say  to  the  child,  "Put  these  two  pieces  to- 
gether so  that  they  will  form  one  card  like  this,"  (indicating  the  oblong 
card).  If  the  child  turns  over  one  triangular  piece  without  noticing  it, 
it  is  permissible  to  begin  again. 


*The  tests  are  modified  to  correspond  to  the  more  advanced  intelligence  of  modern  children. 
tThe  mental  tests  for  children  under  five  years  are  given  on  p.   705. 


754  '  *     DISEASES   OF    CHILDREN 

Ask  child — 

"Is  it  moriiino;  now?"  "Is  it  afternoon?"  "What  is  a  fork?" 
' '  What  is  a  table  ? "  "  What  is  a  chair  ? "  "  What  is  a  horse  ? "  "  What 
is  a  mama?" 

//  same  use  of  three  of  the  objects  is  mentioned  the  response  is  con- 
sidered correct. 

Draw  a  diamond  fijifure  with  ink  and  ask  the  child  to  copy  it,  giving 
him  pen  and  ink  for  the  purpose. 

Place  13  pennies  in  a  row  on  the  table  before  the  child  and  say, 
"Count  these  pennies  for  me,  pointing  to  each  one  as  you  count  it." 

Mental  Age  6  Years 

"Say  after  me,  4,  7,  3,  9,  5,  and  repeat  it  yourself." 

Draw  a  square  3  to  4  cm.  in  diameter  with  ink  and  ask  the  child  to 
copy  it,  giving  him  pen  and  ink  to  do  so. 

Place  one  two  cent  and  one  one  cent  stamp  on  the  table  before  the 
child,  and  then  ask  him  to  count  how  much  they  w^ould  all  cost. 

Have  four  pieces  of  colored  paper,  red,  blue,  yellow,  and  green. 
Point  to  each,  asking,  "What  is  this  color?" 

How  many  fingers  have  you  on  your  right  hand? 

Mental  Age  7  Years 

(a)  "Do  you  know  what  paper  is?"  "Do  you  know  what  cardboard 
is?"    "Are  they  alike?"    "In  what  way  are  they  not  alike?" 

(b)  "Have  you  ever  seen  a  fly?"  "Have  you  ever  seen  a  butterfly?" 
"Are  they  alike?"     "In  what  way  are  they  not  alike?" 

(c)  "Do  you  know  wood  when  you  see  it?"  "Do  you  know  glass 
when  you  see  it?"  "Are  they  alike?"  "In  what  way  are  they  not 
alike?"     Two  satisfactory  answers  required. 

"I  want  you  to  count  backward  from  20  to  0.  Like  this — 20 — 19 — ■ 
18."     This  must  he  accomplished  in  30  seconds.     One  error  allowed. 

"What  day  is  to-day??"     "What  date  is  it?" 

"Listen  well  and  repeat  what  I  say:  3-8-5-7-1;  9-2-7-3-6;  and  5-1-8- 
3-9."    One  group  given  at  a  time. 

Mental  Age  8  Years 

Show  the  child  successively  a  penny,  a  dime,  a  dollar,  a  quarter,  a 
nickel,  a  half  dollar,  a  two  dollar  bill,  a  ten  dollar  bill,  a  five  dollar  bill. 
Ask,  "What  is  this?"  with  each. 

In  a  pile  before  the  child  place  the  following  coins:  Ten  pennies,  two 
nickels,  two  dimes,  one  quarter,  one  half  dollar.     Then  propose  a  game 


AMENTIA  (00 

of  storek('Oi)iii<>',  tlio  eliild  to  kocp  tlic  store  and  use  tlio  ]>il(>  of  money 
to  make  change,  the  exj)erimenter  to  be  the  customer.  Add  some 
articles  for  sale.  Then  bny  something  for  fonr  cents.  Give  the  child 
a  quarter  and  require  the  chang(^ 

"Name  the  months  of  the  year  in  order."  One  error  aUowcd,  time  15 
seconds. 

"If  you  were  going  away  and  missed  your  train,  what  would  you 
do." 

"If  one  of  the  boys  should  hit  you  without  meaning  to,  what  would 
you  do  about  it?" 

"If  you  broke  something  belonging  to  some  one  else,  what  would 
you  do  about  it?"     Two  good  responses  required. 

Mental  Age  9  Years 

Place  on  the  table  before  the  child  five  boxes  weighing  8,  6,  9,  12  and 
15  grams  respectively.  Say  to  him,  "These  little  boxes  all  weigh  dif- 
ferent amounts.  Some  are  heavier  and  some  lighter.  I  want  you  to 
place  the  heaviest  here  and  by  its  side  the  one  which  is  a  little  less 
heavy  and  then  the  one  a  little  less  heavy  and  the  one  still  a  little  less 
heavy,  and  finally  here  the  lightest."  Three  trials  made,  the  hoxes  mixed 
after  each.    Two  successes  in  three  are  required. 

' '  I  am  going  to  show  you  two  drawings!  and  after  you  have  looked  at 
them  I  shall  take  "them  away  and  ask  you  to  draw  them  from  memory. 
You  must  look  at  them  closely  because  you  will  have  them  for  ten 
seconds  and  this  is  a  very  short  time." 

Full  credit  is  given  if  the  whole  of  one  drawing  and  half  of  the  other 
is  reproduced  exactly. 

"I  am  going  to  read  you  some  sentences;  in  each  one  of  them  there 
is  something  foolish  or  absurd.  You  listen  carefully  and  tell  me  each 
time  what  it  is  that  is  foolish." 

{a)  "An  unlucky  bicycle  rider  fell  on  his  head  and  was  instantly 
killed ;  they  took  him  to  the  hospital  and  fear  that  he  cannot  get  well. ' ' 
After  a  pause — "What  is  foolish  in  that?" 

(6)  "I  have  three  brothers,  Paul,  Ernest,  and  myself" — "What  is 
foolish  in  that?" 

(c)  "The  body  of  a  young  girl  cut  into  18  pieces  was  found  j^ester- 
day.    People  think  that  she  killed  herself." — "What  is  foolish  in  that?" 

{d)  "There  was  a 'railroad  accident  yesterday,  but  not  a  serious  one, 
only  48  persons  were  killed." — "What  is  foolish  in  that?" 

(e)  "A  man  said:    'If  I  should  ever  grow  desperate  and  kill  myself 


tSimple   figures,    c.  g..    table,    chair. 


756  ^      DISEASES   OF   CHlIiDREN 

I  should  not  use  Friday  for  the  i)urposo  because  Frdiay  is  an  nnlucky 
day  and  miglit  brin^-  me  nnhappiness.'  " — "What  is  foolisli  in  that?" 
Correct  solution  of  three  of  the  five  statements  required. 

Mental  Age  10  Years  ' 

(a)  "If  yon  were  delayed  on  your  way  to  school,  what  would  you  do 
about  it?" 

(&)  "Before  taking  part  in  something  very  important  what  would 
you  do?" 

(c)  "Why  do  we  more  easily  pardon  a  bad  act  done  in  anger  than 
a  bad  one  done  without  anger?" 

(d)  "If  some  one  should  ask  your  opinion  of  one  whom  you  did  not 
know  very  well,  what  would  you  say?" 

(e)  "Why  should  we  judge  a  person  by  his  acts  rather  than  by  his 
words  ?  " 

Two  errors  allowed. 

Write  the  words  Paris,  fortune,  stream.  Show  them  to  the  child, 
reading  them  to  him  several  times.  Then  give  him  pen  and  ink  and 
tell  him  to  write  a  sentence  containing  all  three  of  these  words. 

Mental  Age  11  Years 

"I  want  you  to  say  just  as  many  words  as  you  can  in  three  minutes. 
Some  boys  say  as  many  as  two  hundred.  Now  you  must  try  and  see 
how  many  you  can  think  of." 

Sixty  words  the  minimum  accepted. 

"What  does  charity  mean?"  "What  does  justice  mean?"  "What 
does  kindness  mean?"     Two  correct  answers  required. 

"Find  the  sentences  which  these  words  make.  Fix  the  words  in  their 
proper  order." 

(a)  At-country-we-for-started-hour-an-the-early. 

( b )  Teacher-I-to-my-exercise-asked-my-correct. 

(c)  Defends-a-his-dog-master-good-bravely. 

The  intelligence  of  a  child  is  judged  not  only  by  the  answer  he 
gives,  but  also  by  the  way  he  gives  it,  and  the  manner  in  which  he  goes 
about  it.  Some  children,  although  very  bright,  may  be  very  careless 
in  listening  to  the  question  and  give  an  answer  .which,  although  not 
correct,  is  nevertheless  very  sensible.  Moreover  it  is  well  to  bear  in 
mind  the  fact  that  some  children  may  be  somewhat  deficient  in  certain  di- 
rections (e.  g.,  drawing)  and  yet  perfectly  normal  as  regards  their 
general  intelligence. 


AMENTIA 


757 


Mental  Affections  in  Older  Children 

Exempting  hysteria,  {q.  v.)  epileptic  idiocy  and  imbecility,  mental 
affections  in  children  under  twelve  years  of  age  are  very  rarely  met  in 
daily  practice,  hence  no  effort  will  here  be  made  to  dwell  upon  the  sul)- 
jeet  very  extensively.  Attention,  however,  will  be  directed  to  the  more 
common,  though  very  rare,  mental  diseases  occurring  in  children  ap- 
proaching puberty  and  adolescence. 

Dementia 

Acute  dementia  is  rare  in  children  under  twelve  years  of  age. 
It  is  apt  to  follow  severe  infectious  diseases,  such  as  typhoid  fever, 
influenza,  or  scarlatina,  or  sudden  shock  and  mental  and  physical 
overexertion.     It  is  manifested  by  gradual  w^eakening  of  the  mind, 


Fig.  227. 


-Dementia  precox  in  a  girl  thirteen  years  old.    Note  also  cystic  degenera- 
tion of  the  thyroid  gland. 


characterized  by  loss  of  memory,  lack  of  power  of  attention,  inter- 
est, and  curiosity,  and  tendency  to  stupor.  After  weeks  or  months  of 
rest,  ample  nutrition  and  tonic  treatment  there  is  usually  a  progress- 
ive return  of  the  intellect  and  gradual  recovery.  More  rarely  it 
terminates  in  permanent  weakmindedness. 

Dementia  Precox  Katatonia  Hebephrenia 

This  mental  affection  is  usually  encountered  in  children  over  ten  years 
of  age,  and  especially  in  girls  at  the  period  of  puberty.    It  usually  begins 


758  DISEASES    OF    CHILDREN 

with  a  prodromic  stage  of  depression  and  apathy  during  which  tlie  cliikl 
loses  interest  in  her  school  work,  and  coniphiins  of  divers  imaginary  ail- 
ments. Loss  of  memory,  especially  for  recent  events,  and  gradual,  pro- 
g:ressive,  intellectual  enfeeblement  form  characteristic  symptoms.  The 
stage  of  apathy  is  soon  followed  by  one  of  anxiety  and  hallucinations  or 
outbreaks  of  emotional  excitement,  silly  and  hilarious  in  nature.  As  the 
disease  advances  the  condition  is  often  complicated  by  manifestations  of 
mania  with  a  marked  tendency  to  destructiveness  and  violence,  oc- 
casionally also  by  attacks  of  stupor,  catalepsy,  affection  of  speech, 
refusal  of  food,  convulsive  movements,  etc. 

In  favorable  cases  the  mental  disturbance  gradually  subsides  within 
a  few  weeks  or  months,  often  leaving  behind  symptoms  of  imbecility. 
In  unfavorable  cases  the  disease  passes  into  a  state  of  total  idiocy. 
Little  if  anything  can  be  done  to  influence  the  course  of  the  affec- 
tion. 

Illustrative  Case  (Fig.  277). — When  I  first  saw  her  she  was  thirteen 
years  old.  She  was  five  feet  six  inches  in  height,  and  slender  in  build, 
weighing  one  hundred  and  twelve  pounds.  Her  general  health  was  good 
and  her  heart's  action  slow  and  regular.  Her  menstruation  had  not  set  in 
and  her  mammary  glands  were  not  developed.  Her  head  was  large  and 
covered  by  a  fair  supph^  of  normal  hair.  Her  eyes  were  large,  but  not 
bulging,  and  her  facial  features  seemed  normal,  when  she  was  not  laugh- 
ing— which  latter  was  rarely  the  case,  especially  when  spoken  to.  When 
addressed  she  would  invariably  grin  (that  peculiar  idiotic  grin)  or  laugh 
aloud  for  several  minutes  at  a  time,  open  her  mouth  very  wide  and  show  a 
set  of  ugly,  big,  blackish  brown,  partially  decayed,  crooked  teeth. 
Examination  of  the  neck  revealed  a  large,  elastic,  cyst-like  swelling, 
spreading  out  as  a  broad  goitrous  mass,  especially  to  the  right.  Ac- 
cording to  the  mother  the  tumor  developed  gradually  within  about  two 
years  previous  to  my  examination.  The  family  history  was  apparently 
negative.  The  parents  were  hard-working,  healthy  people,  and  their 
two  other  children  were  well.  The  patient's  mental  condition  was 
supposed  to  have  been  quite  good  up  to  ten  years  of  age.  At  about 
that  time  it  was  noticed  that  she  lost  interest  in  her  school  work,  be- 
came slovenly  and  forgetful  and  very  "nervous."  As  weeks  and 
months  passed  by  her  feeble-mindedness  grew  more  and  more  pro- 
nounced, so  that  on  coming  under  my  observation  I  found  her  essen- 
tially idiotic.  As  already  stated,  when  addressed  she  would  grin 
and  laugh;  when  questioned  about  something,  she  would  turn  to  her 
mother  and  partly  repeat  what  the  mother  had  to  say;  she  was  unable 


AMENTIA  759 

to  add  together,  for  example,  two  and  two,  and  had  no  idea  of  where 
she  lived.  She  was  extremely  restless  and  disturbed  by  the  slight- 
est commotion,  and  like  a  frightened  baby  was  closely  clinging  to  her 
mother's  side.  I  put  her  on  slowly  increasing  doses  of  thyroid  ex- 
tract, but  it  had  no  beneficial  effect  upon  her  feeble  mentality — her 
condition  remained  stationary  for  several  months.  I  lost  track  of  her 
for  about  six  months  thereafter,  v^^hen  one  day  I  read  in  the  daily 
press  that  on  being  sent  to  a  grocery  store  across  the  street  she  had 
lost  her  way  back  home  and  was  picked  up  by  a  policeman  the  fol- 
lowing day,  exhausted  from  hunger,  thirst,  and  fatigue,  wading  knee- 
deep  in  the  swamps  of  Westchester  and  unable  to  give  any  information 
as  to  her  name  or  place  of  residence.  After  a  few  similar  escapades 
she  was  finally  committed  to  an  insane  asylum. 

Dementia  Paralytica 

Dementia  paralytica,  which  is  very  uncommon  in  children  and 
usually  based  upon  hereditary  syphilis,  presents  identical  symptoms 
as  in  adults.  Thus,  tremor,  slurring  speech,  pupillary  inequality, 
ataxia,  trophic  changes,  and  paresis ;  gradual  loss  of  intellect  with 
development  of  unsystematized  ideas  of  self-importance.  -The  course  of 
this  form  of  dementia  is  chronic  (several  years)  and  invariably  ends 
fatally.  Slight  improvement  may  occasionally  be  observed  from 
cautious  use  of  mercury  and  the  iodids. 

Melancholia 

Mental  depression  is  not  rarely  observed  in  children  from  ten  to 
fifteen  years  of  age  and  sometimes  in  younger  ones.  The  child  re- 
fuses to  play,  laments,  and  cries,  broods  over  imaginary  wrong  acts 
and  occasionally  falls  into  paroxysms  of  rage.  Melancholia  not  rarely 
leads  to  attempts  of  self-destruction. 

The  prognosis  of  this  affection  is  fairly  favorable  (after  weeks  or 
months),  some  cases,  however,  may  proceed  to  mania  or  even  de- 
mentia. 

Rest  and  good  food  are  essential  in  the  treatment. 

Mania 

In  contrast  to  melancholia,  mania  is  characterized  by  accelera- 
tion of  every  physical  and  mental  activity.  Thoughts  and  impulses 
follow  one  another  with  unusual  rapidity.  The  patient  talks, 
rages,  screams  and  tries  to  destroy  everything  in  sight.  She  also 
suffers  from  hallucinations  and  delusions  of  greatness.     While  mania 


760  DISEASES   OF    CHILDREN 

often  ends  in  recovery  after  from  six  to  twelve  months,  it  also  shows 
a  great  tendency  to  recurrence  or  to  alternate  with  attacks  of  melan- 
cholia— circular  insanity — in  which  event  the  prognosis  is  very  bad. 

The  treatment,  in  addition  to  rest  and  proper  nourishment  is  symp- 
tomatic— calming  of  the  excitement  by  means  of  hyoscine  hydro- 
bromate,  and  other  hypnotics.  Luminal,  gr.  ly^  twice  a  day  will  be  found 
exceedingly  useful  as  a  general  nerve  sedative. 

Mental  affections  in  older  children  are  best  treated  in  sanitaria, 
aAvay  from  friends  and  relatives.  As  the  majority  of  them  refuse  to 
eat,  and  as  ample  nutrition  is  essential  to  recovery,  we  are  often  forced 
to  feed  these  patients  by  a  stomach  tube  introduced  through  the  nose. 
Of  course,  for  this  purpose  only  liquid  food  is  available,  such  as  rich 
milk,  fermented  milk,  broths  and  fruit  juices.  Medicines  also  may  be 
given  in  this  manner. 


CHAPTER  XIV 
DISEASES  OF  THE  SKIN 

Skin  affections  of  children  like  those  of  adults  may  be  classified 
into  systemic  and  local.  To  the  former  class  belong  chiefly  the  large 
group  of  exanthemata ;  the  rashes  arising  as  a  result  of  faulty  metab- 
olism and  autointoxication,  including  the  different  forms  of  purpura, 
erythema  and  drug  eruptions;  the  syphilides  and  tuberculous  lesions 
and  the  obscure  dermatoneuroses.  The  local  skin  diseases  embrace 
the  local  parasitic  affections,  the  lesions  following  mechanic,  trau- 
matic, thermic  and  chemic  irritations. 

Since  the  greater  number  of  sj^stemic  morbid  skin  manifestations 
have  received  due  consideration  in  connection  with  the  underlying 
diseases,  we  shall  here  limit  our  discussion  to  the  skin  eruptions  which 
yield  principally  to  local  treatment. 

Eczema 

Eczema  in  children  is  usually  observed  in  subacute  or  chronic  form. 
It  ordinarily  begins  with  localized,  more  rarely  diffuse,  redness  of 
the  skin,  slight  edema,  burning  and  itching.     The  condition  is  soon 


Fig.  228. — Seborrheic  eczema  of  head  and  face. 

aggravated  by  the  appearance  of  papules,  vesicles,  and  pustules,  and, 

if  not  promptly  responding  to  treatment,  by  scabs,  scales  and  fissures. 

Eczema  may  remain  localized,  especially  on  the  face  and  head,  or 

become  generalized.    Eczema  of  the  face  and  head  is  usually  seen  in 

761 


762  DISEASES   OF    CHILDREN 

young  infants,  and  is  very  refractory  to  treatment.  In  its  typical 
form,  the  eruption  of  eczema  faciei  is  generally  spoken  of  as  "crusta 
lactea,"  and  consists  of  more  or  less  coherent  sea])s  of  greenish  or 
blackish-brown  color,  here  and  there  interrupted  by  areas  of  red, 
moist  ("weeping  surface")  and  excoriated  skin.  From  the  face  the 
eruption  usually  extends  to  the  forehead,  ears  and  head  (eczema  or 
seborrhea  capitis).  After  prolonged  duration  the  hair  loses  its  lus- 
ter, becomes  thin  and  short,  and  the  adjacent  glands  are  painful  and 
swollen,  and  often  the  seat  of  a  pustular  eruption  as  a  result  of 
scratching  and  secondary  infection. 

The  course  of  eczema  is  very  tedious.  It  may  last  wrecks,  months, 
or  years.  Improvement  often  alternates  with  aggravation  of  the  con- 
dition. This  is  true  especially  of  eczema  accompanying  constitutional 
derangement,  e.  g.,  gastrointestinal  intoxication  (see  "Exudative  Dia- 
theses." p.  521).  The  duration  of  the  disease  is  often  prolonged  by 
infection  of  the  diseased  as  well  as  healthy  areas  with  divers  parasites 
during  the  act  of  scratching. 

Treatment. — The  success  in  the  management  of  eczema,  depends 
greatly  upon  the  ease  with  which  the  underhnng  causes  can  be  pre- 
vented or  removed.  The  infantile  skin  being  very  delicate  and  vul- 
nerable, it  is  essential  to  avoid  its  undue  exposure  to  mechanical 
(scratching;  woolen,  rough  underwear,  etc.),  thermal  (excessive  heat 
or  cold,  also  direct  action  of  the  sun,  etc.),  and  chemical  (rubefacients, 
irritating  soaps,  urine,  acrid  discharges,  etc.)  irritation.  The  diet 
should  be  bland  and  regulated  as  to  the  time  of  feeding  and  its  quan- 
tity. In  protracted  cases  the  Allergy  test  (g.  v.)  is  often  help- 
ful in  eliminating  the  toxic  etiologic  agent  of  the  disease.  AVhere 
microscopic  and  chemic  examinations  of  the  stools  show  inabil- 
ity to  assimilate  fats  or  carbohydrate,  these  must  be  either  re- 
stricted or  entirely  eliminated.  Sometimes  good  results  are  obtained 
from  removal  of  sugar  from  the  dietary.  Plenty  of  water  is  often 
helpful.  Constipation  should  be  promptly  remedied.  Cleanliness  of 
the  skin  and  everything  coming  in  contact  with  it  should  be  insured. 

The  active  treatment  of  eczema  should  be  regulated  in  accord  with 
the  stage  of  the  disease.  While  the  skin  is  highly  inflamed,  all  sorts 
of  irritation  should  be  interdicted.  Tub  bathing  of  the  entire  body 
should  be  discontinued  for  a  time,  first,  because  of  the  tendency  of 
water  to  irritate  the  denuded  skin,  and,  secondly,  in  view  of  the  pos- 
sibility— particularly  in  eczema  due  to  external  parasitic  infection — of 
conveying  the  disease  from  one  portion  of  the  skin  to  the  other.  The 
healthy  parts  of  the  body,  however,  should  be  kept  scrupulously  clean 
by  frequent  sponging  followed  by  careful  drying. 


DISEASES   OF    THE    SKIX 


763 


The  following  soothing-  and  protective  ointment  employed  Avith 
fjreat  success  at  the  New  York  Post-(!raduate  Hospital,  will  ])e  found 
invaluable  in  the  great  majority  of  acute  or  subacute  cases: 

IJ     Zinci  oxidi, 

Pulveris  creta3   aa  3iv  I   16 

Mix,  and  add  Avith  constant  stirring: 

Olci  lini   (hot), 

Liq.    plumbi   subacet.    dil aa    3ij   I     8 

The  ointment  is  applied  once  or  twice  a  day  thickly  over  the  af- 
fected areas  and  covered  by  sterile  gauze  held  in  place  by  means  of  a 
bandage.  Scratching  of  the  skin  should  be  prevented  by  mechanical 
means,  such  as  ceUuloid  armlets,  and  the  like.  Excoriated  surfaces 
often  heal  promptly  after  painting  with  a  2  per  cent  solution  of 
nitrate  of  silver.  In  subacute  cases  Dunn  recommends  the  following 
ointment : 


IJ     Acidi  Carbolici 

gr.  X 

0.60 

Hydrargyri  Cliloridi  Mitis 

gr.  XV 

1.00 

Amyli 

Zinci  Oxidi 

aa  3i 

4.00 

Vaselini 

Si 

30.00 

M.  Ft.  Ung. 

After  the  inflammation  subsides  and  scales  and  crusts  firmly  adhere 
to  the  skin,  the  soothing  ointments  are  gradually  replaced  by  those  of 
a  stimulating  nature.  The  crusts  are  softened  with  carbolized  oil 
(1  to  100),  and  gently  removed.  The  hairy  portions  of  the  body  are 
carefully  shaved  and  cleansed  with  carbolized  oil.  After  giving  the 
affected  skin  a  few  hours  rest  we  apply  one  of  the  following  prepara- 
tions : 


IJ 


Acidi  salicylici, 

Bismuthi  subgal. 

aa  gr,  xx 

1.3 

Thj-molis 

gr.  V 

0.3 

Pulveris  amyli 

3iij 

12 

Ung.  hydrargyri 

ammoniati 

3ij 

8 

Ung.  zinci  oxidi 

q.s.  ad  Sij 

60 

Ecsorciui 

gr.  XX 

l.S 

Acidi  carbolici 

gr.  X 

0.65 

Olci  cadini 

7/1  XX 

1.3 

Sulphuris  preeipitatis 

3ij 

S 

Ung.  petrolati 

q.s.  ad  Bij 

60 

High  intestinal  irrigation  once  a  day  with  a  quart  or  two  of  plain 
water  or  with  the  addition  of  a  2  per  cent  of  bicarbonate  of  soda  is 


764  DISEASES    OF    CHILDREN 

useful  in  all  cases.  In  gastric  hyperacidity  carbonate  of  magnesium 
(gr.  XXX,  once  a  day)  acts  well.  Obese  children  suffering  from  ob- 
stinate eczema  with  dryness  of  the  skin  often  do  well  on  minute  doses 
of  thyroid  extract.  Finally,  it  is  worth  remembering  that  protracted 
eczema  is  occasionally  a  manifestation  of  hereditary  syphilis,  and  re- 
sponds promptly  to  the  exhibition  of  mercury  and  the  iodides. 

Urticaria 

(Hives,  Nettle  Rash) 

Urticaria  is  characterized  by  a  multiform  eruption  of  whitish,  pink- 
ish, or  reddish  color  upon  dilferent  portions  of  the  body,  which  is 
sudden  in  appearance  and  disappearance,  and  shows  a  tendency  to 
repeated  recurrences.  The  eruption  may  consist  of  circular  or  spiral 
elevations  (''wheals"),  papules,  vesicles,  or  hemorrhagic  spots,  and 
is  generally  associated  with  intense  itching  and  stinging.  It  is  fre- 
quently preceded  and  accompanied  by  gastric  and  nervous  disturb- 
ances and  rise  of  temperature. 

Recurrent  urticaria  is  prone  to  leave  behind  marked  pigmentation 
of  the  skin  or  to  terminate  in  'prurigo,  a  very  chronic  skin  affection 
manifested  by  dryness,  hypertrophy  and  pigmentation  of  the  skin  and 
inflammation  of  the  neighboring  glands. 

Treatment. — Since  in  the  majority  of  instances,  urticaria  in  chil- 
dren is  the  result  of  faulty  feeding,  especially  of  eating  candies  and 
cakes  of  poor  quality,  fish,  fresh  berries,  and  the  like,  it  is  essential 
to  regulate  the  diet*  (in  some  cases  a  milk  diet  is  efficient,  in  others 
again  elimination  of  milk  may  prove  successful),  and  to  clear  the 
gastrointestinal  tract  of  the  obnoxious  material.  The  latter  is  best 
accomplished  by  small  doses  of  calomel,  magnesium  carbonate  and 
sodium  bicarbonate  and  a  high  enema.  To  relieve  itching  we  may 
resort  to  warm  baths  with  bicarbonate  of  soda  (i/^  to  1  pound), 
sponging  of  the  body  with  vinegar  followed  by  glycerine,  or  to  the 
following  preparations: 

IJ     Thymolis  gr.  v  to  x     1     0.3  to   0.65 

Ung.  aquae  rosae  5j     |  30 

M.  S.— P.  r.  n. 


5^     Aqu83  ammonise  3ss 

Aqua)  hamamelidis  Siij 


2 
90 
M.    S. — Not  to  be  used  over  abraded  portions  of  the  skin. 


•See  "Food  Idiosyncrasy,"  p.  87. 


DISEASES   OF    THE    SKIN  TGf) 


n 


s.- 


Acidi  oarbolioi 

3ss 

2.00 

Zinci  oxidi 

Sss 

15.C0 

Glyccrini 

3ii 

8.00 

Aq.  calcis 

Sviii 

240.00 

M. 

-Apply  several  times 

a  day 

and  allow 

to  dr 

y  on  skin 

Intertrigo 

(Chafing) 

This  affection  occurs  "vvith  predilection  in  localities  where  opposed 
body  surfaces  rub  against  each  other,  and  in  the  ''napkin  region." 
It  is  the  result  of  irritation  of  the  skin  by  acrid  secretions  or  ex- 
cretions (sweat,  diarrheal  stools,  acid  urine,  purulent  discharges,  etc.), 
excessive  heat  or  moisture.  Intertrigo  usually  begins  with  simple 
erythema.  At  this  stage  it  readily  yields,  in  addition  to  removal  of 
the  etiologic  factors,  to  the  application  of  a  dusting  powder  of: 


IJ     Zinci  stearatis  3iv 

Bismuthi  subnitratis  gr.  xv 

Amyli  5j 


15 
1 

30 


and  the  separation  of  the  opposed  surfaces  by  thin  layers  of  absorbent 
cotton  or  old,  clean  linen  cloths.  As  the  disease  advances,  the  skin 
becomes  glossy,  moist,  sticky,  and  denuded  of  the  epidermis,  and  the 
seat  of  papules,  abscesses  and  ulcerations.  In  this  condition  inter- 
trigo is  very  refractory  to  treatment,  often  demanding  a  complete 
change  in  the  regime  of  the  baby — beginning  with  its  diet  and  ending 
up  with  its  nurse.  The  customary  daily  tub  bath  should  be  replaced 
by  a  sponge  bath,  taking  special  care  to  keep  the  affected  parts  of  the 
skin  perfectly  dry.  The  denuded  skin  should  once  daily  be  painted 
with  a  1  or  2  per  cent  solution  of  nitrate  of  silver,  and  the  entire  dis- 
eased surface  covered  with  the  following  ointments : 

IJ     Acidi  carbolici, 

Balsami  Peruviani  aa  m  v  I     0.3 

Olei  lini, 
Adipis  lana^, 

Ung.  zinci  oxidi  aa  3iv  I   15 

M.   S. — To  be  applied  several  times  a  day  after  carefully 
cleansing   (with  oil)   and  drying  the  affected  parts. 


IJ     Thymolis 

gr.  ii 

0.13 

Dermatolis 

gr.  viii 

0.5 

Ung.  zinci  oxidi 

q.  s.  5i 

30 

M. 

Sig.— P.  r.  n. 

766 


DISEASES   OF    (nill.DREN 


Psoriasis 

The  disease  is  very  exceptionally  met  in  children  under  five  years 
of  age,  but  is  not  uncommon  in  older  ones.  It  begins  Avith  minute 
white  spots,  usually  upon  the  extensor  surfaces  of  the  elbows  and 
knees  and  upon  the  scalp,  and  gradually  assumes  the  shape  of  disks 
with  tawny-red  base  and  silvery-white  scales,  not  rarely  giving  the 
skin  the  appearance  of  being  splashed  with  mortar.  The  cause  of 
psoriasis  being  obscure  (it  is  probably  of  pai'asitic  origin,  though  it 
seems  to  run  in  families),  the  treatment  is  necessarily  symptomatic; 


Fig.  229. — Psoriasis  in  a  girl  seven  years  old. 

and  very  unsatisfactory  as  to  ultimate  cure.  Internally  we  may  try 
small  doses  of  arsenic,  to  be  continued  for  several  months,  or  thyroid 
extract.  Externally  we  resort  to  alkaline  baths,  and,  after  the  re- 
moval of  the  scales,  to  an  ointment  composed  of  chrysarobin  or  sali- 
cylic acid  and  ichthyol. 


1}     Acidi  salicyli, 

Eesorcini, 

Iclithyolis 

aa  3ss 

2 

Ung.  sulphuris 

Sij 

60 

M. 

S. — To  be  applied  twice  a  day. 

DISEASES   OF    THE   SKIN 


161 


i     Chrysarobini, 

Ichthyolis 

Uiig.  pctrolati 

M. 
S. — To  be  applied  once  or  twice  a  day. 


aa  3j 


4 
60 


Herpes  Zoster 

(Shingles) 

Contrary  to  what  is  observed  in  adults,  herpes  zoster  in  chil- 
dren is  rarely  accompanied  by  severe  neuralgic  pain.  The  eruption 
usually  appears  suddenly  in  the  form  of  groups  of  vesicles  along  the 


Fig.  230. — Herpes  zoster. 

tracts  of  either  the  intercostal  or  pudendal  nerves,  or  the  brachial 
plexus.  The  vesicles  remain  either  isolated  or  coalesce  and  form 
large  patches  covered  by  yellowish-brown  crusts.  Different  patches 
often  exhibit  different  stages  of  development  or  decline.     As  a  rule, 


768  DISEASES  OP  CHILDREN 

the  eruption  is  unilateral.     The  correlation  of  herpes  to  varicella  has 
been  spoken  of  on  p.  395. 

The  course  of  the  disease  is  usually  completed  Avithin  two  weeks, 
except  in  eases  leading  to  deep  ulceration  and  sloughing  (herpes 
gangrenosus),  a  very  rare  condition,  usually  the  result  of  secondary 
infection.  Treatment  consists  of  local  application  of  a  dusting  powder 
or  ointment  composed  of  stearate  of  zinc  with  or  without  2  per  cent 
of  bismuth  subnitrate  or  subgallate.  Occasionally  the  nerve  pain 
calls  for  some  anodyne,  e.  g.,  sodium  salicylate  and  codeine. 

Miliaria;  Lichen  Strophulus 

(Prickly  Heat) 

This  very  common  affection  in  infants,  especially  during  first  denti- 
tion (corresponding  with  the  period  of  excessive  sweating  which 
forms  a  symptom  of  rachitis)  appears  suddenly  upon  the  face,  trunk, 
and  extremities,  either  as  discrete  papules  or  vesicles  from  a  i)inhead 
to  half  a  pea  in  size,  or  in  groups  upon  a  slightly  reddened  infiltrated 
base.  It  is  produced  by  all  sorts  of  external  or  internal  irritations 
(heat,  rough  flannel  underwear,  overfeeding,  etc.),  and  readily  yields 
to  attention  to  these  causes,  and  the  administration  of  mild  laxatives. 
The  slight  itching  may  be  relieved  by  cool,  alkaline  or  bran  baths,  and 
sponging  of  the  body  with  Dobell's  solution.  Prickly  heat  occurs  also 
in  older  children  during  the  summer  months  and  is  best  treated  by  • 
cool  sponging  and  application  of  mentholated  stearate  of  zinc. 

Ecthyma 

(  PSEUDOFURUNCULOSIS  ) 

It  consists  of  pea-  to  bean-sized,  flat  pustules  surrounded  by  a  red 
zone.  The  lesions  are  situated  chiefly  upon  the  thighs,  legs,  shoulders 
and  back,  and  are  frequently  associated  Avith  eczema,  probably  pro- 
duced by  infection  of  the  eezematous  lesions  during  the  act  of  scratch- 
ing. More  rarely,  they  are  met  in  the  newborn  as  a  result  of  lack  of 
cleanliness   (infection  with  dirty  fingers,  cloths,  etc.). 

Occasionally  the  pustules  enlarge  gradually  and  burst,  leaving  be- 
hind deep  ulcers  which  heal  very  slowly  with  scar  formation.  These 
are  prone  to  occur  in  ill-fed,  scrofular  or  otherwise  seriously  diseased 
children,  and  maj'  sometimes  end  fatally  as  a  result  of  gangrene  of 
the  skin. 

Simple  ecthyma  usually  responds  to  hot  baths  (with  boric  acid  gii)* 
antiseptic  ointments,  or  cautious  sponging  of  the  affected  parts  of  the 
body  with  the  following: 


DISEASES   OP    THE   SKIN 


769 


IJ     Ethcris, 

Tr.  sapoiiis  viridis 


afi  5j   I 


3C 


Large  pustules  should  be  treated  by  incision  and  antiseptic  dress- 
ings. (See  ''Scrofulosis, "  p.  460.)  Each  pustule  should  be  covered 
with  zinc  adhesive  plaster  to  prevent  carrying  of  the  pus  to  other  parts 
of  the  body. 

Impetigo  Contagiosa 

The  favorite  seat  of  impetigo  is  the  face,  hands,  and  scalp,  but  the 
other  portions  of  the  body  are  not  exempt  from  the  inoculation. 

The  eruption  begins  as  small  groups  of  minute  vesicopapules  which 
soon  burst  and  dry  up  into  yellowish  crusts.  When  the  crust  has 
lasted  for  some  time,  its  surfaca  becomes  slightly  lamellated  and  its 
edge  detached,  the  crust  then  presenting  the  appearance  as  if  "stuck 


'^^^^^^1 

^^"^B 

/w^s  '        ^^H 

V. 

r 

H^^  .- 

-  k 

Fig.  231. — Impetigo  contagiosa  of  an  unusually  severe  type.     (Courtesy  of  Dr.  L.  W. 

Ketron. ) 

on"  to  the  healthy  skin.  The  surface  beneath  the  crust  is  raw  and 
suppurating. 

If  further  autoinoculation  of  the  disease  is  prevented  (by  covering 
with  gauze  and  zinc  adhesive  plaster),  impetigo  usually  heals  spon- 
taneously in  about  ten  days.  Otherwise,  by  the  development  of  new 
lesions,  it  may  persist  for  several  weeks. 

Treatment. — In  view  of  the  highly  contagious  nature  of  the  dis- 
ease and  its  tendency  to  run  in  epidemic  form  through  schools  or 


770 


DISEASES    OF    CHILDREN 


asylums,  it  is  imporative  to  isolate  all  those  children  who  are  suffer- 
ing from  this  disease  and  to  employ  active  therapeutic  measures  to 
eradicate  it. 

This  is  readily  accomplished  by  means  of  local  antisepsis.  After 
softening  the  crusts  with  warm  carbolized  sweet  oil  (1  per  cent), 
and  removing  them,  and  thoroughly  washing  the  diseased  surface 
with  green  soap,  the  spots  are  touched  up  with  a  2  to  5  per  cent  solu- 
tion of  nitrate  of  silver,  and  covered  over  with  sterile  gauze  and  ad- 
hesive plaster.  This  treatment  is  repeated  for  a  few  days  and  fol- 
lowed up  with  a  25  per  cent  ichthyol  in  a  sulphur  ointment. 

Simple  impetigo  differs  from  the  contagious  variety  by  its  lesions 
being  pustular  from  the  beginning  and  by  showing  no  tendency  to 
coalesce  in  large  patches  and  to  spread  to  other  portions  of  the  body. 
There  is  no  history  of  contagion. 

Pediculosis  Capitis 

(Head  Lice) 

The  favorite  seat  of  the  head  louse  is  the  occipital  portion  of  the 
scalp.    In  cases  where  the  hair  is  thick  and  the  parasites  are  few  in 


Fig.  232. — Pediculosis  capitis,  showing  ova  on  liairs.     (Courtesy  of  Dr.  J.  E.  Lane.) 


DISEASES   OF    THE   SKIN  771 

number  and  hence  not  easily  seen,  their  presence  can  readil.y  be  sur- 
mised by  the  existence  of  ova  (nits),  which  are  firmly  attached  to  the 
shafts  of  the  hair.  The  lesions  produced  by  pediculi  resemble  those  of 
eczema  of  the  head — pustules,  scabs,  matting  of  the  hair,  intense  itch- 
ino:,  and  marked  enlargement  of  the  glands  of  the  neck. 

Treatment. — Children  aiTected  by  pediculosis  should  be  isolated  for 
a  few  days  until  the  disease  is  cured.  The  hair  should  be  clipped,  the 
scalp  thoroughly  cleansed  with  the  tincture  of  green  soap  and  then 
dressed  with  a  cloth  dipped  in  petroleum  or  the  tincture  of  larkspur 
(delphinium).  A  few  such  dressings  usually  suffice  to  effect  a  cure. 
After  removal  of  the  pediculi  the  scalp  should  be  cleared  of  its  re- 
maining eruption  by  an  antisei3tic  ointment  (e.  g.,  unguentum  sul- 
phuris). 

Pediculosis  Corporis 

(Body  Lice) 

Body  lice  are  seldom  seen  in  young  children.  They  give  rise  to 
red  dots,  itching  and  scratch  marks.  The  diagnosis  is  settled  by  find- 
ing the  parasite  in  the  clothing  or  on  the  body  of  the  child. 

Treatment. — The  treatment  consists  in  destroying  or  baking  the 
infested  garments,  scrubbing  the  child's  body  with  green  soap,  and 
the  application  of  a  zinc  and  sulphur  ointment  until  the  eruption  has 
entirely  disappeared. 

Pediculosis  Pubis 

(Crab  Lice) 

This  skin  affection  is  of  diagnostic  interest,  principally  because  of 
the  power  of  the  crab  louse  to  infest  in  addition  to  the  hair  of  the 
pubis,  abdomen,  chest  and  axilla,  also  the  eyebrows  and  eyelashes,  in 
the  latter  case  giving  rise  to  a  clinical  picture  resembling  blephar- 
itis. 

The  insect  succumbs  rapidly  to  the  effects  of  mercury  ointment: 

IJ     Ung.  hydrarg.  nitratis  3j         4 

Ung.  petrolati  3iij       J  2 

M. 

S. — Externally. 

Scabies 

(The  ''Itch'O 

The  erup'tion  of  scabies  is  localized  chiefly  in  places  where  the  skin 
is  thinnest,  i.  e.,  the  hands,  the  folds  between  the  fingers,  the  flexor 


772 


DISEASES   OF   CHILDREN 


surfaces  of  the  wrists,  the  anterior  folds  of  the  axilla,  also  the  back 
and  lower  extremities.  The  characteristic  skin  lesion  of  scabies  is  the 
irregularly  shaped,  brownish-black  ridge  (cuniculus  or  burrow),  the 
result  of  the  burrowing  process  of  the  Acarus  or  Sarcoptes  scabiei. 
The  latter  is  the  cause  of  scabies  and  can  readily  be  demonstrated 
microscopically  in  the  scrapings  of  the  cuniculus.  As  the  disease  ad- 
vances, it  frequently  spreads  over  the  entire  body  and  gives  rise  to 


Fig.  233. — Animal  parasites,  A,  acarus  scabiei,  female  (ventral  surface)  ;  B, 
acarus  scabiei,  male  (ventral  surface);  C,  pediculus  corporis;  D,  pediculus  capitis; 
E,  pediculus  pubis.      (Sutton:   Diseases  of  the  Skin.) 


a  multiform  eruption,  consisting  of  papules,  vesicles,  pustules,  and 
hemorrhagic  spots  (scratch  marks).  It  is  accompanied  by  violent  itch- 
ing, which  is  worse  at  night,  when  the  patient  is  warm  in  bed. 

Treatment. — As  the  disease  is  highly  contagious  (conveyed  through 
close  bodily  contact,  clothes,  underwear  and  bedding),  it  is  advisable 


DISEASES    OF    THE    SKIN 


773 


to  restrict  the  patient  from  too  close  mingling  Avith  other  members  of 
the  family  or  outsiders.  The  patient's  clothes,  l)ed  sheets,  towels,  etc., 
should  be  boiled  and  the  other  unwashable  articles  thoroughly  disin- 
fected. Furthermore,  all  inmates  of  the  house  should  be  examined 
and,  if  necessary,  treated  for  scabies,  lest  the  disease  will  recur 
through  renewed  infection.  The  active  treatment  of  scabies  varies 
with  the  stage  of  the  disease.  Incipient  scabies  responds  promptly 
to  a  few  hot  baths,  thorough  scrubbing  of  the  affected  skin  with  soft 
green  soap  and  the  inunction  of  sulphur  ointment  with  1  per  cent 
carbolic  acid.  The  management  of  advanced  scabies  with  the  same 
therapeutic  measures  is  not  quite  as  satisfactory.  A  number  of  rem- 
edies (strong  ointments  of  carbolic  acid,  naphthol,  creolin,  etc.)  have 


Fig.  234. — Scabies,  in  an  infant.     (Richard  L.  Sutton.) 


been  suggested  for  such  cases,  but  owing  to  their  irritating  qualities 
(upon  the  skin  and  kidneys)  should  be  used  with  caution.  The 
following  combination  will  probably  be  found  to  do  well  in  the  ma- 
jority of  cases : 

IJ     Mcntholis, 

Pulv.  camphora3  aa  gr.  x        0.65 

Olei  cadini, 

Balsami  Pcruviani  aa  3j        4 

Ung.  snlphuris  q.s.  ad  Sij      60 

'       M. 
S. — To  be  applied  in  the  evening  after  a  hot  soap  bath. 


774 


DISEASES   OP    CHILDREN 


For  the  relief  of  itching  we  may  also  try  the  following  ointment 


IJ     Mentholis                                                  gr.  v 

0.3 

Olei  Aiiisi                                              m.  xv 

1.0 

Ung,  Petrolati                                          5  i 

30.0 

M. 

Sig. — Apply  once  or  twice  daily  after  soap  ba 

th. 

Tinea  Trichophytina  Capitis 

(Ringworm  of  the  Scalp,  Herpes  Tonsurans) 

Ringworm  of  the  scalp  is  due  to  the  trichophyton  fungus.     It  is 
highly  contagious  and  often  spreads  with  great  rapidity  and  perti- 


Fig  235. — Trichophyton  tonsurans — threads  and  chains  of  spores  X  400. 
(After  Bizzozero.) 


Fig.  236. — Large-spored  ectothrix  ringworm  of  scalp.     (Richard  L.  Sutton.) 

nacity  in  schools  and  children's  homes  where  great  numbers  of  inmates 
are  crowded  in  comparatively  small  rooms. 

The  eruption  consists  of  ring-shaped,  slightly  elevated,  scaly,  red- 
dish,  grayish,   or   greenish-yellow   patches.     The   hair   over   the    af- 


DISEASES   OF    THE   SKIN  775 

fected  areas  becomes  bi-ittle  and  loose  and  falls  out,  leaving  behind 
bald  shiny  spots. 

At  times  the  eruption  is  accompanied  by  severe  local  inflammation 
and  exudation  of  a  yellowish,  viscid  or  gelatinous  secretion — a  condi- 
tion generally  described  as  tinea  kerion. 


Fig.  237. — Tinea  tonsurans.      (J.  V.  Shoemaker.) 

Treatment. — In  the  treatment  of  ringworm  of  the  scalp  it  is  essen- 
tial not  only  to  prevent  spreading  of  the  disease  from  one  child  to  the 
other,  but  also,  to  prevent  autoinoculation  from  one  part  of  the  scalp 
to  the  other.  This  is  best  accomplished  by  sterilization  (before  and 
after  using)  of  the  hair  clippers,  scissors,  combs,  etc.,  and  thorough 
scrubbing  of  the  scalp  with  the  tincture  of  green  soap  twice  daily, 
and  immediately  after  a  hair  cut. 

In  an  epidemic  at  an  orphan  asylum  comprising  nearly  400  cases  of 
ringworm  of  the  scalp,  I  found  the  following  method  of  treatment 
exceedingly  serviceable: 

;^     Acidi  carboliei, 

Olei  petrolei  aa  3ij   I     65 

Tinct.  iodini, 

Olei  ricini  aa  3iiiss  |   110 

Olei  rusci  q.s.  ad  Sxvj      500 


776  DISEASES  OP  cmr.DREN 

After  clipping?  the  hair  close  to  the  scalp  this  mixture  is  applied 
over  the  entire  scalp — more  thickly  over  the  affected  spots — by  means 
of  a  painter's  brush,  once  a  day  for  five  successive  days.  On  the 
sixth  day  it  is  wiped  off  with  a  rag  dipped  in  plain  olive  oil ;  now  the 
hair  is  clipped  again  and  the  scalp  washed  thoroughly  but  gently 
with  green  soap  and  a  soft  nailbrush,  care  being  taken  that  all  the 
scales  and  loose  hair  covering  the  scalp  are  removed.  As  a  rule,  no 
epilation  is  necessary.  On  the  seventh  day  the  mixture  is  reapplied 
ias  thickly  as  before  and  the  whole  process  repeated  regularly  for 
three  or  four  successive  weeks,  the  length  of  time  depending  on  the 
severity  of  the  case.  New  hair  will  now  be  found  to  appear,  and  no 
trichophyton  fungi  will  be  discovered  in  the  hair  epilated  for  micro- 
scopic examination. 

These  procedures  are  followed  by  a  few  day's  application  of  a  10 
per  cent  sulphur  ointment,  and  then  by  the  use  of  the  following  prepa- 
ration for  about  two  weeks: 


IJ     Eosoreini, 

Acidi  salieyl.  aa  3iv 

Alcoholis  Siv 

Qlei  ricini  q.s.  ad.  Sxvj 


26 
120 
500 


This  mixture  considerably  hastens  the  growth  of  the  hair  on  the 
bald  spots.  In  cases  where  isolation  is  impracticable  or  impossible,  as 
often  happens  in  private  families,  this  resorcin  mixture,  daily  applied, 
serves  as  an  excellent  substitute  to  prevent  spreading  of  the  affection. 
Tinea  tonsurans  is  not  to  be  confounded  with  tinea  favosa,  a  hair 
affection  caused  by  the  Achorion  Schonleinii,  and  characterized  by 
sulphur-yellow,  cup-shaped  crusts  or  scutula,  penetrated  by  a  hair  or  two. 

Tinea  Trichophytina  Corporis 

(Ringworm  of  the  Body,  Herpes  Circinatus) 

Ringworm  of  the  body  begins  as  a  small,  scaly,  circular  spot  which 
rapidly  spreads  peripherally  and  clears  in  the  center,  resembling  a 
"ring"  in  shape.  The  rings  frequently  coalesce,  forming  serpiginous 
lesions. 

It  is  a  trivial  eruption  and  promptly  yields  to  a  few  local  applica- 
tions of  the  tincture  of  iodine,  white  precipitate  ointment  or  glacial 
acetic  acid  (to  be  applied  lightly  once  every  other  day). 

MoUuscum  Contagiosum 

Contagious  molluscum  is  not  rarely  met  in  epidemic  form  in  large 
institutions  for  children.  The  etiologic  factor  of  the  disease  is  as  yet 
unknown. 


DISEASES   OP    THE    SKIN 


777 


The  eruption  appears  principally  upon  the  face,  eyelids,  neck  and 
arms  and  consists  of  discrete,  semiglobular,  waxy-white,  umbilicated, 
small  (up  to  a  split  pea)  wart-like  elevations,  Avith  sebaceous  con- 
tents. 

It  is  a  benign  affection  and  readily  curable  by  ablation  of  the 
nodule  or  expression  of  its  contents,  and  cauterization  with  tincture 
of  iodine  or  5  per  cent  salicylic  acid  in  collodion. 

Telangiectases,  Nevi  and  Angiomas 

(Birth  Marks) 

Telangiectases  are  usually  small,  flat,  superficial,  radiating  pink  to 
bluish-red  patches  composed  of  a  fine  vascular  net  work. 

Nevi  are  bluish-red  to  dark  blue,  flat,  or  elevated  neoplasms  of  con- 
siderable size.  Nevi  pigmentosi  may  be  yellow,  brown,  blue,  black, 
or  grayish  in  color ;  if  covered  by  hair,  they  are  spoken  of  as  nevi  pilosi. 

Angiomas  are  true  vascular,  spongy  tumors  raised  above  the  skin 
and  containing  hollow  spaces  filled  with  blood.    They  have  a  tendency 


I 


Fig.  238. — Vascular  nsevus.      (Dr.  E.  L.  Suttou.) 

to  enlarge  rapidly  and  there  is  danger  of  ultimate  sarcomatous  de- 
generation. On  the  other  hand,-  some  of  them  undergo  spontaneous 
evolution.  Hence,  in  cases  which  do  not  disfigure  the  patient  and  do 
not  make  rapid  progress,  it  is  often  advisable  to  postpone  treatment 
as  long  as  possible.  Small  birth  marks  frequently  disappear  under 
the  application  (every  third  day)  of  a  solution  of  corrosive  sublimate 
in  collodium  (6  per  cent);  or  a  single  drop  of  a  30 — volume  of  hydro- 
gen dioxide  is  applied  by  means  of  a  glass  rod  twice  daily.  If  these 
procedures'  fail,  we  have  to  resort  to  electrolysis  or  excision  and  liga- 
tion. 


778  DISEASES   OF    CHILDREN 

Combustio 

(Burns) 

In  accordance  with  the  degree  of  severity  of  the  inflammation  and 
destruction  of  tissue,  burns  are  generally  classified  as  follows : 

1.  Dermatitis  Ambustionis  Erythematosa. — The  surface  is  reddened, 
somewhat  swollen  and  painful  and  the  seat  of  small  vesicles. 

2.  Dermatitis  Ambustionis  Bullosa. — Blisters  and  bulla?  of  variable 
size,  marked  edema  and  redness  of  the  contiguous  tissues.  Severe 
pain. 

3.  Dermatitis  Ambustionis  Escharotica. — Complete  destruction  of 
the  integument  and  subcutaneous  tissue,  often  also  the  muscular  and 
fibrous  tissues  and  even  the  bone.  Surrounding  skin  blanched  and 
markedly  edematous.     Sloughing  of  central  portion. 

Extensive  burns  in  children,  even  if  only  superficial,  give  rise  to 
intense  constitutional  symptoms,  such  as  shock,  fever,  vomiting,  diar- 
rhea and  sometimes  convulsions.  In  an  infant  under  observation  a 
superficial  burn  of  the  neck  was  productive  of  serious  edema  glot- 
tidis,  threatening  asphyxia.  Severe  burns  may  prove  fatal  from  shock 
within  the  first  forty-eight  hours  or  later  from  complicating  erysipe- 
las, duodenal  ulcer,  pyemia,  pneumonia  or  tetanus. 

Treatment. — Superficial  burns  generally  improve  rapidly  under 
dressings  with  warm  boracic  acid  solutions  or  carron  oil.  In  order  to 
avoid  detachment  of  the  skin  on  changing  the  dressings,  it  is  advisable 
to  cover  the  moist  dressing  with  rubber  tissue  and  bandage.  Large 
blisters  may  be  punctured  with  a  sterile  needle.  After  the  inflam- 
matory symptoms  have  subsided  the  following  ointment  will  prove 
very  efficient. 

5 


Bismuthi  subnitratis, 

Resorcini 

aa  gr.  x 

0.60 

Balsami  Peruviani 

3ss 

2.00 

Ung.  zinci  oxidi 

li 

30.00 

M.  ft.  ung. 

Exuberant,  bleeding  granulations  may  be  reduced  by  daily  paint- 
ing with  a  2  per  cent  nitrate  of  silver  solution.  In  large  and  deep 
burns  the  recently  recommended  method  of  treatment  by  means  of 
paraffin  wax,  is  undoubtedly  the  best.  The  mode  of  application  is  as 
follows : 

1.  Melt  the  wax  to  fluidity,  and  while  moderately  hot, 

2.  Paint  raw  surface  of  burn,  until  thoroughly  covered. 

3.  Apply  thin  layer  of  absorbent  cotton. 


DISEASES   OF    THE    SKIN  779 

4.  Paint  absorbent  cotton  with  a  heavy  coat  of  the  Avax. 

5.  Cover  with  several  hiyers  of  gauze,  cotton  and  bandage. 

6.  Change  dressing  daily  or  every  other  day. 

The  wax  should  be  melted  in  a  sauce  pan  over  a  free  flame.  A  large 
camel's  hair  brush  is  used  for  painting. 

The  constitutional  symptoms  should  receive  prompt  attention. 
Bromides,  small  doses  of  codeine,  and  sterile  camphorated  oil  hypo- 
dermically  are  indicated  in  the  majority  of  cases.  In  the  case  re- 
ferred to  an  ice  bag  seemed  to  do  most  good  to  relieve  the  edema  of 
the  glottis. 

Congelatio 

(Frostbite;  Chilblain) 

Frostbites  are  quite  common  in  children  who  are  more  or  less 
anemic.  It  is  usually  manifested  by  redness,  heat,  itching,  smarting 
and  burning.  In  severe  cases  blisters  may  develop,  as  a  rule,  from 
scratching,  and  end  up  in  indolent  ulcers.  Frostbites  usually  affect 
the  most  exposed  parts,  such  as  the  hands,  feet,  ears,  cheeks,  nose  and 
lips,  and  are  apt  to  return  yearly  with  the  advent  of  fall  and  winter. 
Chilblains  of  the  fingers  and  toes  should  not  be  mistaken  for  acute  in- 
flammatory rheumatism,  which  is  a  febrile  affection. 

In  the  management  of  frostbites  due  consideration  should  be  given 
to  the  underlying  constitutional  debility  (administration  of  iron  and 
codliver  oil)  and  proper  clothing  suitable  for  the  season  of  the  year 
(flannel  or  silk  underwear,  etc.).  Locally  the  parts  should  be  bathed 
in  hot  water,  and  painted  with  balsam  of  Peru  or  ichthyol.  A  very 
useful  ointment  is  the  following : 


IJ     Camphora) 

Oroosoti  aa  gr.  xv 

Balsami  Peruviani 

Ichthyolis  a  a  3ss 

Ung.  petrolati  Si 

M.  S. — To  be  applied  once  or  twice  a  day. 


1.0 

2.0 
30.0 


INDEX 


Al)domen  and  its  contents,  146 

anatomy    of,    147 

enlargement  of,   151 

retracted,    in    tubercnlous    meningitis, 
612 

size  and  shape  of,  150 
Al)doniinal,    parietes    congenital    defects 
of,  187 

pain,    151 

tulterculosis,    154 

tumors,  153 
Abnormal  baby,  701 
Abscess,  brain,  in  ear  disease,  304 

cerebral,  621 

in  spondylitis,  462 

peritonsillar,  294 

psoas,  466 

retropharyngeal,  302 

tubercular,   in  coxitis,  469 
Acarus,   or   sarcoptes   scabiei,   772 
Acetonuria,  161,  522 

test  of,  524 
Achondroplasia,   512 

differentiated   from   rachitis,   510 
Achorion  Schonleinii,  776 
Acid  intoxication,  522 
Acidosis,   522 

complicated  by  pyelitis,  523. 
Acids,  mineral,   105 
Addison's  disease,  556 
Adenie,  550 
Adenitis,  559 

in  glandular  fever,  405 

in  rubella,  364 

in  scrofula,  459 

in  tuberculosis,  446 
Adenoids,   298 

dangers   and   accidents   after   removal, 
300 

postoperative  treatment  of,  300 

removal  of,  299 
Adhesio  linguae,  177 
Adipositas,   520 
Aerocele,  180 

Aestivoautumnal  fever,  407 
Airing  of  baby,  66 
Albinism,  17^ 
Alcoholism  and  degeneracy,  762 


Albuminuria,   161 

cyclic,     functional,     lordotic,     orthotic, 
582 

in  nephritis,  574 
Alimentary  tract,  diseases  of,   233 

malformations   of,   183 
Allergy  test,   87 

in  asthma,  337 

in  eczema,  762 
Alteratives,   105 
Amaurotic  family  idiocy,  716 

differentiated       from       microceplialus, 
709 
from  rachitis,   718 

juvenile  form  of,  717 

macular  changes  in  eyes,  717 
Amebic  dysentery,  413 
Amentia,   690 

classification   of,   706 

diet  in,   738 

etiology  of,  690 

incentive  training  of,   741 

in  older  children,  751 

medicinal  treatment  in,  746 

physical   therapeutics  in,   739 

prognosis  of,  750 

surgical  treatment  of,  749 
Amnion  navel,  188 
Amyatonia  congenita,  204 
Amygdalitis,  293 
Amyloid  disease  of  liver,  285 
Anemia,   cerebral,   600 

pernicious,  551 

pseudoleukemic.  Von  .Taksch,  549 

simple,  547 

splenic,  549 
Angina,  293 

differentiated  from  diphtheria,  294 
from  influenza,  294 
from  scarlatinal  angina,  386 
Angina  Ludoviei,  387 
Angioma,  777 
Aniridia,  179 

Animation,  suspended,  213 
Anklc-elonus,   171 
Ankyloblepharon,    178 
Ankyloglossia,  177 
Ankylostomiasis,  281 
Annulus  migrans,  238 
Anodynes,  107 
Anophthalmus,    177 
Anthelmintics,  280 


781 


782 


INDEX 


Antibubonic  serum,  HOO 
Anticostive  triad,  262 
Aiitidiplithcritic  serum,  75 
in  diphtheria,  370 
in  noma,  236 
in  scarlatinal  anj^ina,  392 
Antidysenterie   serum,   414 
Antimeningitis  serum,  78 

Intravenous  injection  of,   80 
in  meningitis,  615 
Antipneumonic  serum,  327 
Antipyretics,   106 
Antirheumatics,   106 
Antispasmodics,   107 

Antistreptococcic     serum     in     scarlatina, 
393 
in   malignant   endocarditis,   536 
Antitetanic   serum,   77 

in  tetanus  neonatorum,  227 
Anuria,  160,  586 
Anus,  absence  of,   185 

imperforate,  186 
Aortic,  obstruction,  539 

regurgitation,  539 

stenosis,  congenital,  528 
Aphthae,  Bednar's,   234 

stomatitis,  234 
Apoplexia,   neonatorum,   208 

in  older  children,  603 
Appendicitis,  269 

differentiated  from  acidosis,  523 

from  intussusception,  267 

from   peritonitis,   267 
Argyll  Eobertson  pupil,  121 
Aromatic  baths,  92 

Arteritis  and  phleliitis  umbilicalis,  228 
Arthritis,  418 

deformans,  420 

gonorrheal,   418 

rheumatic,  416 

rheumatoid,  418 

septic,  418 

syphilitic,  418,  421 

tuberculous,  421,  461 
Articular  osteitis  of  hip,  466 
Artificial   feeding    of   infants,   48 
Ascaris  lumbricoides,   276 
Aspersion  bath,  91 
Asphyxia  neonatorum,   213 
Aspidium,    in   treatment    of   tape   worm, 

281 
Aspiration,    of   cerebral   ventricles,   209 

in  pleural  effusions,  334 

pneumonia,  369 
Assimilation,  faulty,  55 

of  casein,  56 

of  sugar,  36 
Astasia  abasia,  683 
Asthma,  337 

thymicum,   568 
Astringents,   intestinal,    112 


Ataxia,  diphtheritic,  369,  666 

hereditary,  657 
Atelectasis  neonatorum,  213 
Athetosis,  619 
Athletics,  67 

in  heart  disease,  542 
Athrepsia,  501 
Atresia,  ani,   186 

auris,  180 

esophagi,   183 

hymenalis,  197 

intestines,  183 

posterior  nares,  179 

pupillae,   178 

recti,   186 

urethrse,  193 

vaginae,   197 

vulvae,  197 
Atrophy,  infantile,  501 

of  liver,  acute  yellow,   285 

myogenic,  neural,  spinal,   658 
Atropine,  in   pyloric  stenosis,  248 
Attention,  power  of,  702 
Attitude   of  head,   118 
Auditory,   meatus,   absence   of,   180 
Auricular,  appendages,  179 
Auscultation,  of  heart,  131 

lungs,  129 


Babinski's  sign,   171 

in  meningitis,  607 
Babies,    mentally    deficient,    690 
Bacterial  vaccines,  81 
Bacteriuria,  164 
Banti's  disease,   557 
Barley  Avater,  49 
Barlow's  disease,  514 

differentiated  from  rheumatic  arthri- 
tis, 418 
Basedow's  disease,  563 
Bathing  of  baby,  65 

Baths,   medicated   and   nonmedicated,   90 
Bednar's  aphthae,  234 
Bed-wetting,  587 
Bell's  palsy,  663 
Beriberi,  517 

yeast   in,   517 
Bier  's  passive  hyperemia,  471 
Binet-Simon  mental  tests,  753 
Biologic  diagnosis  and  therapeutics,  71 
Birth,  injuries,  207 

marks,  777 

paralysis,   208 
Bitter  tonics,  103 
Black,  death,  500 

measles,  361 

smallpox,  397 
Bladder,     congenital    malformations    of, 
192 


INDEX 


783 


Bladder— Cont  'd 

diseases  of,  584 

stones,   586 

tuberculosis,  457 
Bleeders,  552 
Bleeding  from  navel,  222 

from    nose,    289 
Blindness,  acquired,  223 

congenital,  177 
Blood,  coagulation,   552 

count,  differential,  547 

diseases,  546 

normal,   546 
Blue  sickness,  525 
Bone,  cyst  of  humerus,  478 

diseases,  204 

tuberculosis,   461 

tumors,  476 
Bothrioceplialus  latus,  280 
Boundaries,  of  heart,  140 

lungs,  133 
Bowlegs,   rachitic,   507 
Brachial  paralysis,  211 
Bradycardia,  in  influenza,  353 
Brain,  abscess,  304,  621 

anemia,  600 

degeneration,  708 

diseases,  596 

embolism,   604 

hemorihage,  603 

hyperemia,  601 

localization,  602 

miniature,  707 

syphilis,  488 

tuberculosis,  452 

tumors,  645 

tumor  differentiated  from  abscess,  623 
from  gumma,   647 
from  iiysteria,  648 
from  Jacksonian  epilepsy,  648 
from  tubercle,  647 
Bran  baths,  92 
Branchial  appendages,  181 
Branchiogenetic  cysts,  181 
Break-bone  fever,  410 
Breast,  inflammation  in  the  newborn,  232 

nipples,  attention  to,  44 

pump,  44 
Breast  milk,  42 

analysis  of,  45 
Breathing  exercises,  439 
Breck's  fever,  217 
Brissaud  type  of  infantilism,  726 
Bronchial  glands,  tuberculosis   of,  444 

tubes,   diseases   of,   314 
Bronchiectasis,  340 
Bronchitis,  acute,  314 

capillary,  315 

chronic,    31(? 

fibrinous,  315 


Bronchopneumonia,  316;  lobular,  difTer- 
entiated  from  lobar  pneumonia, 
325 

Bronzed  skin,   556 

Brudzinski's  sign,  in  meningitis,  007 

Bubonic   plague,   499 

Buhl's  disease,  230 

Burns,  778 

treatment  with  paraffin  wax,  778 

Buttermilk,  57 


Calculi,    renal,    578 

vesical,   586 
Calmette-tuberculin-reaction,  83 
Calmuck  type  of  Mongolian  idiocy,  720 
Camp-fever,  404 
Cancrum  oris,  234 
Capacity  of  infantile  stomach,  55 
Capillary  bronchitis,   315 
Caput  succedaneum,  207 

differentiated    from    cephalhematoma, 
208 
Carbohydrates,  digestion  of,  32 

kinds  of,  34 

metabolism  of,  35 
Cardiac  cases,  exercise  in,  542 
Cardiac  cirrhosis  of  liver,  284 
Care  of  the,  eyes,  64,  223 

newly  born,  64 

teeth,  440 

umbilicus,  221 
Caries  of  vertebral  column,  462 
Carpal   bones,   undevelopment   in   idiocy, 

728 
Casein,  faulty  digestion  of,  56 

milk,  57 
Casts,  in  urine,   162 
Cataract,   congenital,   178 
Cathartics,    111 
Caudal  formations,   200 
Central,  birth  palsy,  208 

pneumonia,   321 
Cephalhematoma,  207 
Cephalocele,  174 

differentiated     from     cephalhematoma, 
208 
Cerebral,  abscess,  621 

convulsions,  differentiated  from  eclamp- 
sia,  670 

facial    paralysis,    differentiated     from 
peripheral,  665 

hemorrhage,  208,  603,  714 

hyperemia,  601 

localization,  602 

paralysis,   601 

tumors,  645 
Cerebrospinal  fluid,  normal,  609 

pathologic,  611 

withdrawal  by  lumbar  puncture,  610 
by  puncture  of  subdural  space,  210 


784 


INDEX 


Cervical  ril),  181 

mistaken  for  spondylitis,  464 
Cervicitis,  589 
Chafing   (intertrigo),  765 
Chaulmoogra  oil,  in  leprosy,  499 

in  tuberculosis,  451 
Cheiloschisis,  175 
Chest,  abnormal  shape  of,  132 
Chicken-breast,   507 
Cliickcn  pox,  394 
Chilblain,  779 
Chloroma,  differentiated  from  scorbutus, 

516 
Chlorosis,  547 

Choked  disc,  in  cerebral  tumors,  646 
Cholera  infantum,   250 
Chondrodystrophia  foetalis,  512 
Chorea,.  678 

eleetrica,   682 

insaniens,  680 

magna,  685 

minor,   678 

mollis,   679 

])aralytic,  679 

rhythmica,  685 

vera,  678 
Choroidal  tubercles,  453 
Chvostek's  phenomenon  in  tetany,  673 
Chylothorax,  333 
Circular  insanity,  760 
Circulatory  system,  diseases  of,  525 
Circumcision,  194 
Circumference  of,  chest,  132 

head,  116 
Cirrhosis  of  liver,  284 

case  report,  284 
Cleft,  bladder,  192 

face,  175 

palate,  176 

vertebral  column,  197 
Climatotherapy,  100 
Clothing  of  infant,  65 
Clubfoot,    202 

treatment  of,  203 
Clubshaped  fingers,  in  bronchiectasis,  340 

heart  disease,  525 
Coccygeal  tumors,  200 
Cold,  compresses,  90 

effects  of,  89 

packs,  89 

sponging,  89 
Cod-liver  oil  mixture,  451 

in  tuberculosis,  451 

in  rachitis,  512 
Colic,  intestinal,  257 

renal,  578 
Colieystitis,  584 
Colitis,  253,  412 

Collapse  of  the  lungs  (atelectasis),  213 
Coloboma  iridis,  179 


Colon,   congenital    dilatation    and   hyper- 
trophy, 184 
Colostrum,  44 

Conibustio   {see  Burns),  778 
Communicable   diseases,   345 

prevention  of  spreading  of,   68 
Complement-fixation  reaction  in  tubercu- 
losis, 84 
Compress,  Priessnitz  's,  90 
Condensed  milk,  56 
Condyloma,  syphilitic,  484 
Congelatio   {see  Frostbite),  779 
Congenital  malformations  {see  Malforma- 
tions),  174 
Conjunctiva,  tuberculin  test  of,  83 
Constipation,   157 

"anticostive  triad"  in,  262 

chronic,   259 

electricity  in,  97 
Consumption,  hasty,  442 
Contractures,  of  extremities,  167 

hysterical,  683 
Convulsions,  699 
Cor  bovinum,  537 
Cdrd,    uml)i]ical,   care   of,   221 
Coryza,  288 
Coush,  138 
Cow 's  milk,  48 

composition  of,  48 

feeding  of,  48 

substitutes,   56 
Coxa    vara,    differentiated    from    coxitis, 

470 
Coxitis,  tuberculous,  466; 

differentiated  from  rheumatism,  470 
Crab-louse,  771 
Cranial  bones,  117 
Craniotabes,  505 

Cream,  percentage  in  top  milk,  49 
Crede's  method  of  prevention  of  gonor- 
rheal ophthalmia,  223 
Creeping-pen,  67 
Creosote  in  tuberculosis,  451 
Cretinism,  721 

endemic,   goitrous   or  sporadic,  563 

differentiated  from  Mongolism,  720 
from   rachitis,  725 
Croup,  diphtheritic,  367 

false,  309 

spasmodic,  309 
Croupous  pneumonia,  320 
Crusta  lactea,  762 
Cryptophthalmus,   178 
Cryptorchidism,  195 
Curvatures  of,  extremities,  166,  507 

spine,  463,  479 
Cyanosis,  congenital,  525 

icterica,  229 
Cyclic,  albuminuria,  582 

vomiting,  522 


INDEX 


785 


Cysticerci  in  the,  brain,  648 

muscles,  425 
Cystitis,  584 
Cytocliagnosis,  of  cerebrospinal  fluid,  611 


D 


Dactylitis  in,  frambesia,  496 

leprosy,  497 

syphilis,  492 

tuberculosis,  472 
Darwin  's  theory  of  heredity,  modification 

of,  691 
Deaf-mutism,  387,  730 
Deafness,  scarlatinal,  387 

syphilitic,  491 

tests  of,  306 
Death,  thymus,  568 
Dementia,   757 

paralytica,  759 

precox,  757 
Denjjue.  410 
Dentitio  difficilis,  236 
Dermatitis,  ambustionis,  778 

exfoliativa,  neonatorum,  225 
Dextrocardia,  529 
Diabetes,  foods  in,  519 

insipidus,  520 

mellitus,  518 
Diacetic  acid,  test  of,  524 

in  urine,  161,  523 
Diagnostic,  lines  of  thorax,  134 

significance  of  large  abdomen,  151 
Diaphoretics,  110 
Diarrhea,  157 

and  vomiting,  250 
Diastasis  recti  abdominis,  187 
Diazo-reaction  in  typhoid,  400 
Dietary  in,  amentia,  738 

normal  baby,   60 
Differential  diagnosis  of,  arthritides,  418 

diphtheria  and  angina,  374 

exanthematous  diseases,  398 

meningitides,  613 

pneumonia  and  pleurisy,  324,  325,  333 

valvular  heart  diseases,  539 
Difficult,  feeding,  55 

teething,  236 
Digestants,    103 
Digestibility  of  carbohydrates,  32 

of  proteins,  26 
Digestive  ferments  in  intestines,  33 
in  pancreas,  32 
in  saliva,  32 
in  stomach,  32 
Diluents  for  cow 's  milk,  49 
Diphtheria,  365 

antitoxin,    75,   221,   236,   370,   594 

croup,  367 

difPerential'diagnosis,  374 

immunization,  75 


Diphtheria — Cont  'd 

intubation  in,   376 

laryngeal,   367,   375 

nasal,  367 

omphalitis,   221 

paralysis,  369,  6f)6 

pathology  of,   365 

Schick's  reaction  in,  371 

serum,  74 

susceptibility  to,  74 

toxin-antitoxin,  75 

tracheotomy  in,   381 

treatment  of,  370 

vulvae,  594 
Diplegia,  603 

spastica  infantilis,  615 

with  amentia,  713 
Diplopia,  121 

in  lethargic  encephalitis,  626 
Disinfection,  68 

solutions  for,  70 
Dislocation  of  hip,  congenital,  201 

septic,   220 
Disseminated  sclerosis,  657 
Diuretics,   110 
Diverticulum,  Meckel 's,  191 
Dome-shaped  skull,  708 
Double  jointed,  508 
Dropsy  of  the,  brain,  596 

nephritis,  573 
Dry  milk,  58 

manufacture  of,  58 
Duchenne-Erb  paralysis,  211 
Ductless-glands,  diseases  of,  546 
Ductus,     arteriosus     Botalli,     persistence 
of,  526 

omphalomesentericus,    190 
Dukes'  disease,  394 
Dysentery,  412 

serum,  414 
Dyspepsia,  248 

classification  of,  248 
Dyspituitarism  and  hydrocephalus,  600 
Dystonia   musculorum    deformans,   688 
Dystrophia,    adiposogenitalis,    570 

muscularis,  659 
Dysuria,  586 


E 


Ear,    affections,    303 

appendages,   122 

foreign  bodies  in,   303 

malformations,   179 

semeiology   of,   122 
Eclampsia,  infantile,   669 

differentiated  from  epilepsy,  669 
from  meningitis,   613 
from  uremia,   670 
Ecthyma,  768 


786 


INDEX 


Ectopia,  cordis,   529 

vesicae,  192 

viscerum,   188 
Eczema,   761 
Edema,   of  eyelids,   120 

glottidis,   313 

scleredema,   218 
Eiweiss  milk,  57 
Electricity^  96 

Embolism  of  cerebral  arteries,  604 
Emetics,  109 
Emphysema,  piilmoiium,  339 

cutis    {see    Piieumohypoderma),    344. 
Empyema,   331 

necessitatis,  332 
Encephalitis,   epidemic,   lethargic,   624 

differentiated     from     meningitis     and 
brain  tumor,  623 

nonsuppurative,  620 

suppurative,  621 
Encephalocele,   174 
Enchondroma,  174 
Endocarditis,  acute,  533 

chronic,   536 

differentiated    from    pericarditis,    536 

malignant,   535 
English  disease   {see  Eachitis),  503 
Enteralgia,   257 
Enteric  fever,  399 
Enteritis,   248 
Enteroclysis,  94 
Enterocolitis,   248 
Enuresis,   587 

electricity  in,  97 
Eosinophilia  in,  asthma,  338 

scarlatina,  388 
Epidemic    hemoglobinuria    with    icterus, 

229 
Epilepsy,  649 

differentiated  from  eclampsia,   669 
from  hysteroepilepsy,  686 

Jacksonian,  650 

nutans.  651 

procursiva,  651 

with  idiocy,  712 
Epiphyseolysis  in,  osteomyelitis,  475 

rachitis,  508 
Epiphysitis,   syphilitic,  485 
Epispadias,  193 
Epistaxis,   289 
Epithelial  pearls,  234 

differentiated    from    ulcerative    stoma- 
titis, 234 
Erb's,  paralysis,   212 

sign  of  tetany,  673 
Eruptive  fevers,   differential   table,   398 
Erysipelas,   neonatorum,    229 

in  omphalitis,  221 
Erythema  nodosum,  424 
Escherich's  incubator  room,  216 
Esophagitis,   239 


Esophagus,  diseases  of,  239 

stenosis,  congenital,  183 
Eustachian  tul)e,  catarrh  of,  303 
Examination  of  the  patient,  115 
Exanthematous       diseases,       differential 

chart,  398 
Exercise,  66 

in  heart  diseases,  542 

in  lung  diseases,  439 
Exfoliative  dermatitis,   225 
Exomphalos,   188 
Exophthalmic  goiter,  563 
Exostoses,  multiple,  426 
Expectorants,   110 
Expectoration,  138 
Extremities,  abnormalities  of,  166,   201 

curvatures  of,  166 

muscular   contractures   of,   167 

muscular  weakness  of,  167 

paralysis  of,  168,  601 

shortness  of,  166 

spasmodic  movements  of,  167 

tumefactions  of,  166 
Exudative   diathesis,  521 
Eyes,  appearance  in  disease,  120 

care  of  in  the  newly  born,  64,  223 

changes  in  amaurotic  family  idiocy,  717 

changes  in  meningitis,  608 

congenital,  absence  of,  177 
Eyelids,   semeiology   of,   120 

F 

Face,  semeiology  of,  118 
Facial,  hemiatrophy,   665 

paralysis,  electricity  in,  98 
in  poliomyelitis,   635 
nuclear,  664 
peripheral,  210,  663 
Family,  history  in  disease,  115 

idiocy,  716 

splenomegaly,   558 
Faradic  current,  97  ^ 

Fat,  breast  milk,  46 

in  stools,  39 

metabolism,    37 

percentage  in  cow 's  milk,  48 

retention,  38 

vegetable,  41 
Fatty,     degeneration     in     the     newborn, 
acute,  230 

liver,  285 
Febris,  intermittens,  406 

recurrens,   404 

rubra,   382 
Feeble   vitality   of   the   newborn,   213 

treatment  of,   216 
Feeding,     of     infants,     artificial     cow's 
milk,  48 

mother's  milk,   42 

of  older  children,  60 

scheme,  53 


INDEX 


787 


Fetor  ex  ore,  124 

P^ever    charts    of,    endocarditis    maligna, 
534 

influenza,  S.IO 

rubella,  363 

ru1)eola,   3;j9 

scarlatina,   400 

tuberculous  meningitis,  G12 

typhoid,  400 
Fever,  glandular,  40.") 

malarial,  406 

relapsing,   404 

rheumatic,   414 

typhoid,  399 

typhus,  404 

yellow,  411. 
Filatov-Koplik   spots,   3;j9 
Fistula    colli   congenita,   180 
Fits,  epileptic,  649 
Flatulence,  colic,  257 
Flaxed  poultice,  in  pneumonia,  318 
Fkxner's   serum    in,    dysentery,   414 

meningitis,  615 
Floating  kidney,  192 
Flu   {see  Influenza),  345 
Fontanelles,   117 

Foods,   allergy   or  idiosyncrasy   tests   of, 
87 

composition    of,    62 

in  diabetes,  519 

in  infants,  42,  48,  60,  738 
Foramen  ovale,  persistence  of,  526 
Foreign  bodies  in,  ear,  303 

esophagus,   239 

intestines,  266 

larynx,   314 

nose,  290 
Formaldehyd-potassium-permanganate 

fumigation,  71 
Fourth  disease,  394 
Fragilitas  ossium,  205 
Frambesia.  496 
Friedreich's  ataxia,  657 
Frohlich's  syndrome,  570 
Frost  bite,   779 
Fumigation,  71 

Functional  diseases  in  the  newborn,  231 
Funnel    shaped    chest,    acquired    in    ade- 
noids,   297 

and  rickets,  507 

congenital,  182 
Furunculosis  of  ear,  303 


G 

Gait,  semeiology  of,  170 
Galvanic  current,  96 
Gangrene  of,  genitalia,  594 

lungs,   341 

navel,  221 

skin  in  varicella,  395 


Gastralgia,  257 
Gastric   sedatives,   112 
Gastritis,  250 
Gastroenteritis,   acute,  248 

chronic,   253 

subacute,  253 

tetanism  in,  254 

treatment  of,  254 
Gavage,  216,  615 

Genitalia,    congenital    malformations    of 
164 

diseases  of,  589 
Genu,  valgum,  508 

varum,   508 
Geographic  tongue,  238 
German  measles,  363 
Gibbus    {see   Kyphosis),   465 
Glands,   bronchial,   tuberculosis   of,   444 
Glandular,  fever,  405 

therapy,   113 
Glossitis,  238 
Glottis,   edema   of,   313 

spasm    of,    677 
Glycosuria.   160,   518 
Goiter,  561 

exophthalmic.   563 
Gonorrheal,   arthritis,   418 

differentiated    from    rheumatic    arthri- 
tis, 418 

ophthalmia,  222 

proctitis,   592 

vulvovaginitis,   591 
Granuloma  of  the  umbilicus,  222 
Graves'  disease,  563 
Green,   sickness,  547 

tumor.  516 
Grip,   345 
Groats  water,  49 
Grocci's  sio^n,  in  pleurisy,  329 
Gunmia,  492 
Gums,  semeiology  of.  124 

bleeding   from,  514 
Gymnastics,  in  heart  disease,  .542 


H 


Habit,  spasm,  681 

Half-cretin,  724 

Hand-trident,  in  achondroplasia,  513 

in    cretinism,    722 
Hare  lip,  175 
Head,   attitude   of,  in   disease,   118 

circumference,    116 

louse,  772 

nodding,  682 

semeiology  of,  116 
Headache,  sick,  653 

in  brain  tumor,  645 
Health  resorts,  100 
Hearing,  defective,  122,  701 

tests  of,  306 


INDEX 


Heart,  apex,  142 

boundaries,  140 

dilatation,   537 

diseases,  acquired,  529 

diseases,  congenital,  525 

dullness,   140_,   144 

exercises   in   disease  of,   542 

hypertrophy,  537 

nuirinurs,   143 

normal,   140 

paralysis  in  diphtheria,  369 

percussion  of,  131 

sedatives,  109 

skiagrams,  140,  537 

sounds,   143 

stimulants,  108 

transposition  of,  529 

valvular  disease  of  the,  536 
Heat,  effects  of,  88 
Hebephrenia,  757 
Hectic  fever,  446 
Height,  173 

Hcine-Medin-disease,  627 
Hematoma,  sternoclcidomastoidei,  208 
Hematuria,  semeiology  of,  162 
Hemianopsia,  semeiology  of,  121 
Hemiatrophy,  facial,  665 
Hemichorea,  679 
Hemicrania,  653 
Hemiplegia,  601 

double,   603 

spastica  infantilis,  618,  637 
Hemoglobinuria,  581 

paroxysmal,  582 

with  icterus,  epidemic,  229 
Hemophilia  (see  Hemorrhea),  552 
Hemoptysis,  446 
Hemorrhage,  cerebral,  208,   603 

cutaneous,  554 

in  influenza,  351 

intestinal,  412 

intracranial,  208,  603 

meningeal,  603 

nasal,   289 

postoperative,  after  adenectomy  or  ton- 
sillectomy,  297 

pulmonary,  446 

rectal,   257 

renal,  583 

spinal,  655 

subperiosteal,    515 

umbilical,  222 
Hemorrhea,  acquisita,  553 

congenita,  552 

differentiated  from  exanthemata,  scurvy 
and  septic  purpura,  555 

treatment  of,  553,  555 
Hemorrhoids,  differentiated  from  procti- 
tis,  257 
Hemothorax,  343 
Henoch  's  purpura,  555 


Hepatitis,  interstitial,   syphilitic,  486 
Hereditary   ataxia,   657 

atropliy,  progressive,   muscular,   658 
Heredity,   in  mental   deficiencies,   perma- 
nent and  temporary,  691 
Hernise,  151 

cerebral,  174 

inguinal,     differentiated     from     psoas 
abscess,  466 

spinal,   197 

uml)ilical,  197 
Herpes,   circinatus,   776 

tonsurans,   774 

zoster,    767 
Herter's  infantilism,   727 
Hip,  congenital  dislocation  of,  201 

joint  disease  tuberculous,  466 

malformations,  201 
Hirschsprung's  disease,  155,   184 
History  of  patient,  the  taking  of,  115 
Hives,  the,  764 
Hodgkin's  disease,  550 
Holt's  milk  testing  set,  45 
Home-made  liquid  capsules,  104 
Home-modification  of  cow's  milk,  51 
Hookworm   disease,  281 

thymol  in,  282 
Horseshoe  kidney,  192 
Hot   baths,  91 
Hutchinson 's,  teeth,  490 

triad  of  syphilis,  490 
Hydatid     cyst     of     liver,     differentiated 
from  abscess,  tumor  and  pleuri- 
tic effusion,  286 
Hydrocele,  195 
Hydrocephalocele,  174 
Hydrocephaloid,  251,  600 
Hydrocephalus,  117,  452,  596,  710 
Hydronephrosis,  580 
Hydrotherapy,  88 

Hydrothorax,   differentiated   from   pleur- 
isy, 333 
Hygiene  and  sanitation,  64 

in  amentia,  737 
Hygroma,  cysticum  colli  congenitum,  181 

differentiated  from  goiter,  562 

sacral,  200 
Hymen,  atresia  of,  197 
Hyperemia,  cerebral,  601 

passive.   Bier's   method    of   treatment, 
471 
Hyperidrosis,  in  rachitis,  506 

in  German  measles,  363 
Hyperpituitaria,  570 
Hypertrophy   of,  brain,   712 
colon,   184 
differentiated    from    pericarditis    Avith 

effusion,  532 
heart,   540 
tonsils,   296 


INDEX 


789 


Hypnotics,  107 
Ilypodcrinoclysis,  94 
Hypopitiiitnria,  570 
Hypospadias,  193 
Hypotliyroidism,  563 
Hysteria,   682 

differentiated  from  epilepsy,  G86 

electricity  in,  98 

phantom  abdominal  tumor  in,  684 
Hysterical  contracture  of  lower  extremi- 
ty,   differentiated    from   coxitis, 
683 
Hysteroepilepsy,  686 


Icterus,   catarrhal,   283 

epidemic  with   hemoglobinuria,   229 

neonatorum,   231 
Idiocy,    690 

amaurotic,  702,  716 

Calmuck  type,  720 

classification  of,  706 

cretinic,   721 

diagnosis  of,  696 

epileptic,  751 

etiology  and  pathology  of,  690 

hydrocephalic,  710 

mental  tests  in,  705 

microcephalic.  702 

Mongolian,  718 

paralytic,   712 

prophylactic   and   active   treatment   of, 
732 
Idiotic   status   or   attitude,   702 
Ileocolitis,  epidemic,  412 
Imbecility,  752,   753 
Imitation  power  of,  in  idiocy,   703 
Immunity,  26,  71 
Immigration,   71 
Impetigo,  contagiosa,  769 
Incentive  training  in  idiocy,  739 
Incontinence  of  urine,  587 
Incubator  room,  216 
Indigestion,   248 
Infant,  feeding,  26 

stools,   55,    158 
Infantile,   atrophy,   501 

muscular  atrophy,  659 

paralysis,  627 
Infantilism,  726 

Infarct,   uric  acid,  in   the   newborn,   231 
Influenza,  345 

differentiated  from  typhoid  fever,  402 

pathology   of,   346 

vaccine   in,  354 
Inhalations,   medicated,   311,   373,   433 
Inherent  strength,  25 
Injections,  intestinal,  94 

intraperitoneal,   95,   251 
Insanity,  757 


Intelligence,   defective  in   idiocy,   704 

normal,  698 
Intermittent   fever,  406 
Intertrigo,    765 
Intestines,  atony  of,   147 

catarrh  of,  248 

congenital  malformations  of,  IB."', 

differentiated   from   strangulation,   267 

diseases  of,  248 

intussusceptions  of,  264 

syphilis  of,  488 

tuberculosis  of,  453 

worms  in,  276 
Intubation,  in  diphtheria,  376 

feeding  after,  380 
Intussusception,  264 

differentiated  from  prolapsus  recti,  261 
Intravenous  injection  of  serum,  in  menin- 
gitis, 80 
Invagination,    intestinal,    264 
Irideremia,  179 
Iridoschisma,  179 
Iris,  fissure  of,  179 
Irrigations,  intestinal,   93,   94 
Ischuria,  586 
Isolation  of  patient,  69 
Itch,  the,  771 


Jacksonian   epilepsy,   650 
Jail-fever,  404 
Jaundice,  catarrhal,  283 

epidemic,    229 

in   the  newborn,   231 
Juveiiile  form  of,  amaurotic  idiocy,  717 

muscular  atrophy,  659 


K 


Kakke   {see  Beriberi),  517 
Karell's  diet  in,  heart  disease,  545 

nephritis,  578 
Katatonia,  757 
Keratitis,   interstitial,   syphilitic,   491 

phlyctenular,  459 
Kernig's  sign  of  meningitis,   171,  607 
Kidney,  anatomy  of,  49 

congenital  malformations  of,  192 

diseases  of,  572 

stones   in,   578 

tuberculosis  of,  457 

tumors  of  the,  582 
Knee  jerk,  171 

joint  disease,  470 
Knock-knees,  508 
Koplik-spots  in   measles,   359 
Kyphosis,  rachitic,  507 

tuberculous,  465 


790 


INDEX 


Laboratory  milk,  104 
Labyrinth  disease,  308 
Landry's  paralysis,  6.3.5 

diflfcrentiated    from    multiple    neuritis, 
668 
Laryngeal  tumors,  .313 
Laryngismus  stridulus,  309 
Laryngitis,   acute,   308 

catarrhal,  309 

chronic,   311 

diphtheritic,  367 

differential  diagnosis,  310 

between  catarrhal,  syphilitic  and  tu- 
berculous laryngitis,   312 

membranous,  nondiphtheritic,  309 

spasmodic,  309 

stridula,  309 
Laryngocele,   180 
Laryngospasmus,   677 
Larynx,  foreign  bodies  in,  314 

malformations  of,  180 
Lavage,  93 
Laxatives,  111 

Leichtenstern 's   sign    of   meningitis,   608 
Length  of  child,  171,   173 
Leucocythemia,  .5.50 
Leukemia,  .550 
Leprosy,  497 

chaulmoogra  oil  in,  499 
Lethargic,   encephalitis,   625 

differential  diagnosis  from  similar  af- 
fections, 626 
Lice,  body  and  head,  776,  777 
Lichen  strophulus,  768 
Lien  mobilis,  556 
Lingua  geographica,  238 
Lipodystrophia,  progressiva,   661 
Lipomatosis  universalis,  520 
Lips,   semeiology   of,   123 
Little's  disease,  615 

with  amentia,  713 
Liver,  abscess,  285 

abscess    differentiated    from    pleurisy, 
286 

amyloid    degeneration   of,   285 

anatomy  of,  147 

cirrhosis  of,  284 

fatty,  285 

sugar  coated.   285 

tumors    of,    286 
Lobar,  pneumonin,  320 
Lobular  pneumonia,  316 
Lordosis,  481 

albuminuria  in,  .582 
Lumbar  puncture,  610 

in  meningitis,   610 

in   poliomyelitis,   642 

in  scarlatinal  uremia,  392 


Lungs,   auscultation   of,   129 

boundaries   of,   134 

collapse,  congenital,  of,  213 

diseases,  314 

percussion  of,  130 
Luschka 's   tonsil    {see  Adenoids),   298 
Luxatio  coxae  congenita,  201 
Lymphadenitis,    559 

tuberculosis,  458 
Lymphadenoma,  550 
Lymphangioma   cysticuni,  181 
Lymphatic  glands,  semeiology  of,  129 


:m 


McEvvcn    sign    in    meningitis,   608 
Macroce2:»halus,    differentiated    from    hy- 
drocephalus,  712 
Macroglossia,   177,  726 
Macrostomia,   76 
Macular    changes    in    amaurotic    family 

idiocy,  717 
Malaria,  405,  408 

differentiated   from   miliary   tuberculo- 
sis,  443 

from  typhoid,  402 
Malformations,    congenital,    of    the    ali- 
mentary tract,   183 

bladder,  192 

brain,   174 

ears,  179 

extremities,  201 

face,  175 

genitourinary   tract,   192 

head,  174 

heart,  525 

larynx,    180 

mouth,  177 

neck,  180 

nose,   179 

thorax,   182 

tongue,  177 

trachea,   180 

vertebral  column,  197 
Malt,  baths,  92 

soup,  56,  503 
Mania,  759 
Marasmus,  501 

differentiated   from  miliary  tuberculo- 
sis,  444 
Massage,  99 

Mastitis  neonatorum,  232 
Mastoiditis,  303 
Masturbation,  593 

Materia  Medica  and  therapeutics,  88,  101 
Measles,  358 

German  or  Liberty,  363 
Meckel 's  diverticulum,  191 
Medicated  baths,  91 
Medication,  select,  palatable,  101 
Megacolon  congenitum,  184 


INDEX 


791 


Melancholia,   759 

Melena  neonatorum,  229 

Meloschisis,  176 

Meningeal  hemorrlins'o,   208,    603 

Meningitis,  acute,  60o 

cerebrospinal,  605 

cerebrospinal  fluid  in,  609 

differential  diagnosis,  613 

Flexner  's  serum  in,  609 

in  mastoid  disease,  304 

serosa,  598 

spinal,  655 

syphilitic,  614 

tuberculous,  605,  614 
Meningocele,   174 

spinal,   197 
Menstruatio  precox,  594 
Mental,  deficiencies  in  infants,  690 

diseases  in  older  children,  757 

retardation,  728 

stigmata   of  degeneration,   697 

tests,  705,  753 
Mercurial  baths,  92 
Mesocardia,  432 

Metabolism,   of   carbohydrates  and   fats, 
35,  37 

disturbances  of,  501 
Microccphalus  Avith  idiocy,  702,  707 

differentiated   from  Mongolism,   720 
Micromelia,   512 
Microphthalmus,   178 
Microscopy  of  human  milk,  42 
Microstomia,  177 
Migraine,  653 
Miliaria,  768 
Miliary   tuberculosis,   442 

differentiated    from   lobar    pneumonia, 
325 

from  typhoid   fever,  402 

skiagram,  of,  443 
Milk,  casein,  57 

composition  of  cow 's  and  human,  48 

condensed,  56 

cow's  feeding  of,  48 

dry,  58 

eiweiss,  57 

formulas,  53 

home  modified,  52 

laboratory,  51 

pasteurized,   51 

peptonized,  59 

protein,  57 

sterilized,  51 

substitutes  of,  56 

top,  49 

woman 's,  42 
Mineral  acids,   105 
Miniature  brain,  702 
Mitral  heart  disease,  539 
Moeller-BSrloAv's    disease    (see    Scurvy), 
514 


Molluseum   eontagiosum,   776 
Mongolian  idiocy,  718 

differentiated    from    amaurotic    idiocy, 
718 
from  cretinism,  720,  725 
from  microccphalus,  709 
Monoplegia,  603 
Monorchidism,  195 

Moramentia    (retarded   mentality),    728 
Morbilli,  358 
Morbus,    Addisoni,   556 

coeruleus,  525 

coxarius,   466 

maculosus  Werlhofii,  554 
Moron,  753 

Moro's  tuberculin  test,  38 
Mosquitoes  as  carriers  o^,  dengue,  410 

malaria,  405 

yellow  fever,  411 
Motion,  voluntary  power  of  in  amentia, 

703 
Mouth,   diseases   of,   233 

semeiology  of,  123 

wash,  235 
Multiple,  exostoses,  426 

neuritis,   98,   665 

sclerosis,  657 
Mumps,  427 

secondary,  238 
Muscles,  atrophies,  658 

congenital  affections  of,  204 

spasms  of,  167 

thoracic,   defects  of,   183 

weakness  of,   167 
Mustard,  baths,  92 

water  compresses,  in  pneumonia,  326 
Myatonia  congenita,    (Oppenheim),  204 
Myelitis,  656 
Myelocystocele,   197 
Myelomeningocele,  197 
Myocarditis,  529 
Myositis,  425 

ossificans,   426 

scarlatinal,  387 
Myotonia  congenita   (Thomsen),  205 
Myxidiocy,  563,  721 


N 


Nasal,  discharge,  122 

hemorrhage,  289 

obstructions,  congenital,  179 

tuberculin  test,  83 
Nauheim  baths,  91 
Navel,  affections  of,  219 
Neck,  semeiology  of,  129 

rigidity   of    (see  Opisthotonos),  607 
Nephritis,  acute,  572 

chronic,  577 

diphtheritic,  368 

scarlatinal,  388 


792 


INDEX 


Nejihritis — Cont  'd 

varicellosa,  395 
Nephrolithiasis,  578 
Nerve   diseases,   596 
Nettle  rash,  764 
Neuritis,  differential  diagnosis,   668 

diphtheritic,  multiple,  665 
Nevus,  777 
Newborn,  care  of,  64 

diseases  of,  213 

feeble   vitality   of,   213 

injuries  of,  207 

whooping  cough  in  the,  434 
Night,  terrors,  654 

sweats,  447 
Noguchi's,  Wassermann  reaction  in  syph- 
ilis, 85 

Leptospira  icteroides,  in  yellow  fever, 
411 
Noma,  faciei,  234 

in  measles,  361 

vulvae,  594 
Nona,   (see  Lethargic  Encephalitis),  624 
Nose,  bleeding,  289 

diseases,  288 

malformations  of,  179 

semeiology  of,  123 
Nursery,  67 
Nursing,  maternal,  43 

wet  nursing,  46 
Nutrition,  26 
Nystagmus,   semeiology  of,   120 


O 


Oatmeal  water,  49 

Obesity,  520 

Obstetric  paralysis,   brachial,   211 

facial,  210 
O  'Dwyer  's  intubation  set,  378 
Oliguria,  160 
Omphalitis,   219 
Omphalocele,  188 

Omphalomesenteric   duct,   persistent,   190 
Omphalorrhagia,  222 
Onanism,  593 

One-day-fever  (see  Glandular  fever),  405 
Ophthalmia,  gonorrheal,  592 

strumous,  459 
Ophthalmoblennorrhea   neonatorum,   222 
Opisthotonos,  607 

Optic  neuritis  in  cerebral  tumors,  646 
Organotherapy,  113 
Orthotic  albuminuria,  582 
Osteitis,  473 

of  hip,  466 
Osteogenesis  imperfecta,  205,  511 
Osteomyelitis,  473 

differentiated  from  rheumatic,  419 

syphilitic,  491 

tuberculous,  461 


Osteosarcoma,  476 
Otitis,  303 

Oxyuris   vcrmicularis,   276 
Ozena,  289 


Pack,  cold,  89 

vapor,  89 
Palatable  medication,  101 
Palate,   semeiology  of,   126 

malformations,   of,   176 
Papilloma,  laryngeal,   313 
Paraffin  wax  in  l)urns,  778 
Paralysis,  brachial,   211 

cerebral,  208,  601 

diphtheritic,  368 

facial,  nuclear,   664 

facial,  peripheral,  210,  663 

infantile,  627 

of  extremities,  167 

pseudobulbar,  603 

pseudohypertrophic,   659 

spastic,  618 
Paralytic,  amentia,  712 

dementia,  759 

idiot,   714 
Paramyoclonus   multiplex,   682 
Paraplegia,  656,  657 
Parasites,  intestinal   (see  worms),  276 
Parasituria,  164 
Parasyphilis,   490 

Parathyroid  gland   (sec  Organotherapy), 
113 

in  amentia,  747 

injury  in  pertussis,  434 

injury  in  tetany,  673 
Parotitis,  epidemic,  427 

secondary,   238 
Parrot 's,  nodes,  486 

pseudoparalysis  in  syphilis,  486 
Passive  hyperemia.  Bier's  method,  471 
Pasteurization  of  milk,  51 
Pavor  nocturnus,  654 
Pearls,  epithelial,  in  stomatitis,  234 
Pectus  carinatum,  in  rachitis,  507 
P'edatrophy,  501 
Pediculosis,  capitis,  770 

corporis,  771 

illustrated,  772 

pubis,   771 
Poliosis   rheumatica,  424 

differentiated  from   scorbutus,   516 
Pellagra,  517 
Pemphieus,  neonatorum,  224 

syphilitic,   484 
Peptonized  milk,  59 
Peptonuria,  semeiology  of,  163 
Perception,  power  of,  in  amentia,  703 
Percussion,  of  thorax,  129 

resonance  abnormal,   137 


INDEX 


793 


Pericanlitic   psoiuloeirrliosis    (Pick's  dis- 
ease), 285 
Pericarditis,  530 

differentiated   from   endocarditis,   536 
from  pleurisy,  333 

purulent,  532 
Periosteal  reflex,  171 
Periostitis,  473 

Peripheral,  facial  palsy,  210,  663 
Peritonitis,  acute,  275 

differentiated     from,     intussusception, 
267 
rachitic  abdominal  enlargement,  155 

tuberculous,  453 
Peritonsillar  abscess,  294 
Perityphlitis,  269 
Pernicious  anemia,   551 

serum  treatment  of,  551 
Perspiration,  excessive  in,  German  meas- 
les, 364 

rickets,  506 
Pertussis,  429 

in  the  newly  born,  434 
Pestis    Americana    {see    Yellow    Fever), 
411 

bubonica,  499 
Pharyngitis,  292 

Phenolsulphonephthalein   test   in   nephri- 
tis, 578 
Phimosis,   193 
Phlyctenular  keratitis,  459 
Phthisis  pulmonum,  444 

differentiated  from  bronchiectasis,  340 
Physical,  examination  of  the  patient,  115 

therapeutics  in  amentia,  739 
Pick's  disease,  285 
Pineal  gland  extract,  113,  747 
Pin-worms,   276 
Pituitary   gland,   diseases   of,   570 

extract,  113,  747 
Plague,  bubonic,  499 
Plasmodium  malarise,  405,  plate  XI 
Pleuritis,  327 

chylous,  333 

differentiated  from  liver  abscess,  286 
from  pneumonia,  333 

dry,  327 

hemorrhagic,  330 

purulent,  331 

serous,  330 

tuberculous,  330 

with  effusion,  328 
Pneumohypoderma   (sec  Emphysema  Cu- 
tis), 344 
Pneumonia,  alba,  482 

aspiration,  369 

croupous,  320 

flaxseed  poultice  in,  318 


Pneumonia — Cont  'd 

lobar,  320 

differentiated    from   bronchoi)ncumo- 
nia  and  miliary  tuberculosis,  325 
from  meningitis,  613 
from  pleurisy,  333 
pathology  of,  320 

lobular,   316 
Pneumothorax,  343 

artificial     in     pulmonary     tuljerculosis, 
452 
Polioencephalitis,  627 

Struempell  type,  618,  637 
Poliomyelitis,  627 

diagnosis,   640 

differentiated    from    multiple    neuritis, 
668 

electricity  in,  98 

pathology  of,  630 

serum    in,    642 

treatment,  medical  and  surgical  of,  641 
Polyarthritis,   acute,    414 
Polymyositis,   425 
Polyneuritis,  665 

epidemic  (see  Beriberi),  517 
Polyuria,   520 

semeiology  of,  159 
Pot-belly  in  rickets,  509 
Pott's  disease,  462 
Poultice  of  flaxseed  meal,  in  pneumonia, 

318 
Power  of  resistance,  26 
Precocious  puberty,  571 
Premature  birth,   214 

management  of,  216 
Prepuce,    congenital    malformations    of, 

193 
Prevention  and  control  of  disease,  25 
Prickly  heat,  668 
Priessnitz  's  compress,   90 
Proctitis,  257 

gonorrheal,  592 
Progressive,  muscular  atrophy,  658 

torsion  spasm,  688 
Prolapsus  ani   et   recti,   263 

in  rickets,  509 
Prophylaxis,  68 

in  amentia,  732 
Protein,  milk,  57 

digestibility  of,   26 

faulty  digestion  of,  56 
Prurigo,   764 
Pseudofurunculosis,  768 
Pseudohypertrophic  paralysis,  659 
Pseudoleukemia,  infantum,  549 

lymphatica,  550 
Pseudomeningocele,  174 
Pseudoparalysis,   in   rickets,    509 

in  scurvy,  515 

in  syphilis,  486 
Pseudotetanus,  676 


794 


INDEX 


Psoas  abscess,  466 
Psoriasis,   766 
Puberty  precocious,  571 
Pulmonary    artery,    stenosis,    congenital 
of,  528 

valve,  affections  of,  540 
Pulsation  in  neck,  someiology  of,  129 
Pulse  rate,  semeiology  of,  142,  145 
Pupils,   semeiology   of,   120 
Purgatives,  111 

Purpura  fulminans,  hemorrhagic,   simple 
and  Werlhof's,  554,  555 

rheumatic,  424 

differentiated  from  scorbutus,  516 

vaccinatoria,    73 
Purulent  ophthalmia,  222 
Pyelitis,  580,  584 

with  acidosis,  523 
Pyelocystitis,  584 
Pyelonephritis,  580 
Pyloric  stenosis,  242 

medical  and  surgical  treatment,  245 
Pylorospasm,  242 
Pyopneumothorax,  343 
Pyothorax,  331 
Pyuria,  163 

Q 

Quarantine,  68 

Quinine  in,  malaria,  408 

whooping   cough,  433 
Quinsy,  293 

E 

Eachitis,   503 

abdominal    enlargement    in,    differenti- 
ated from  tuberculous  peritoni- 
tis, 154 
acute  (see  Scorbutus),  514 
amaurotic  family  idiocy,  718 
cod  liver  oil  in,  512 
differentiated  from  achondroplasia,  510 
from  cretinism,  725 
from  hydrocephalus,  711 
fetal,  512 

kyphosis  in,  differentiated  from   spon- 
dylitis,  507 
osteogenesis  imperfecta,  511 
Eanula,  237 

Eectuni,  discharges  from,  semeiology  of, 
165 
malformations  of,  186 
prolapse  of,  263 

differentiated    from    intussusception, 
254 
Eecurrent,    cyclic,    vomiting    (see    Acid- 
osis), 522 
Eeflexes  of  tendons,   171 
Eelapsing   fever,   404 
Eemittent  fever,  407 

differentiated   from    meningitis,   614 


Een  mol)ilis,   192 
Eenal,  calculi,  578 

hemorrhage,   162,  583 
Eesorcin -alcohol,    in    scarlatinal    angina, 

391 
Eespirations,  semeiology  of,  134 
Eespiratory,   diseases,   287 

sounds,  136 
Eetropharyngeal,    abscess,   301 
Bheumatic  fever,  414 

torticollis,  417 
Eheumatism,  414 

acute,  414 

articular,  414 

chronic,  420 

diff'erential  diagnosis,  418 

electricity  in,  98 

muscular,  416 

nodosiis,  424 

scarlatinal,  387 
Eheumatoid   arthritis,  420 
Ehinitis,  288 

diphtheritic,  367 
Eibs,  cervical,  181 

cervical,  mistaken  for  spondylitis,  464 

semeiology  of,  182 
Eice  water,  49 
Bickets   (see  Eachitis),  503 
Eigidity,  of  limbs  (see  Little's  disease), 
615 

of  the  neck,  129 

in  meningitis,  607 
Eingworm,  of  body,  776 

of  head,  774 
Eoeky  Mountain  fever,  399,  410 
Eoentgen-ray  diagnosis  in  pleurisy,  329 
Eoseola,  epidemic,  363 
Eotheln,  363 
Eubella,  363 
Eubeola,   358 


S 


Sacral  tumors,  200 

Saint  Vitus'  dance,  563 

Salaamkrampf    (see    Epilepsia    nutans), 

651 
Saline  injections,  94 

hypodermic,  intraperitoneal,  intrasinus 
and  intravenous,  95 
Saliva,  semeiology  of,  128 
Salivary  glands,  diseases  of,  237 
Salivation,  237 
Salvarsan,  its  administration  in  syphilis, 

495 
Sanitation,  64 
Sarcoma  of,  bones,  476 

kidney,  583 
Sarcomphalos,  222 
Scapulse,  abnormal  posture  of,  133 


INDEX 


795 


Scarlatina,  382 

maligna,   gravissima   s.   fulminans,   389 

seasonal  prevalence  of,  383 
Scarlatinal,  angina,  386 

differentiated    from    diphtheria,    375 

nephritis,   388 

otitis,  387 

rheumatism,   387 

uremia,  388 
Scheme  for  infant  feeding,  53 
Schick's  reaction  in  diphtheria,   7-1 
Schoenlein's  disease    {see  Peliosis  Eheu- 

matica),  424 
Scissors  gait   {sec  Little's  disease),  615 
Scleredema  neonatorum,  218 
Sclerema  neonatorum,  218 
Sclerosis,  disseminated,  multiple,  657 
Scoliosis,  479 

rachitic,  507 

in  poliomyelitis,  637 
Scorbutus,  514 

differentiated  from  cliloroma,  epiphysi- 
tis syphilitica,  osteomyelitis,  pel- 
iosis rheumatica,  purpura  hem- 
orrhagica  and   rachitis,   516 
from  poliomyelitis,    639 
from  rheumatism,   418 
Scrofnlosis    {see   Tuberculosis),   458 
Scrotal  tongue,  in  Mongolism,  719 
Scrotum,  absence  of,  185 

tumefactions  of,  164 
Scurvy,  514 
Sea-salt  baths,  92 
Seborrhea  capitis,  761 
Select,  palatable  medication,  101 
Semeiology  of  disease,  115 
Sepsis  neonatorum,  general,  226 

local,  219 
Septic  arthritis,  differentiated  from  rheu- 
matism, 418 

sore  throat,  293 
Septum  ventriculosum,  defects  in,  527 
Serum   diagnosis  of,   syphilis,  85 

tuberculosis,   84 

typhoid  fever,  86 

typhus  fever,  86 
Serum,  bubonic  plague,  500 

diphtheria,  75 

dysentery,  414 

meningitis,   78 

pneumonia,  327 

poliomyelitis,  642 

tetanus,   77 
Seven-day-fever,  410 
Shingles   {see  Herpes  Zoster),   767 
Ship  fever,  404 
Sick  room,  68 
Simon's   triangle,   eruption   in    smallpox, 

39,6 
Sinus  thrombosis,  604 

intrasinus  injections,  95  ^ 


Sinusitis,   291 

Skin  diseases,  761 

Skull,  semeiology  of,  116 

sugar  loaf  shape,  708 
Sleep,  64 

"Sleeping  sickness"   {see  Lethargic  En- 
cephalitis), 625 
Smallpox   {see  Variola),  395 
Smell,  abnormal  sense  of,  in  amentia,  701 
Snuffles,  in  syphilis  neonatorum,  483 
Soap  bath,  92 
Soor,  233 
Sore  throat,  293 
' '  Spanish  influenza, ' '  3-15 
Spasmodic  laryngitis,   309 
Spasmophilia,  668 

in  rickets,  510 
Spasms,  eclamptic,  669 

glottis,  677 

habit,  681 

nutans,  682 

rotatory,   682 

torsion,  progressive,  688 

vesical,  586 
Spastic  paralysis,  618,  637 

semeiology  of,  167 
Speech,    development   of,   699,    704 
Spina  bifida,  197.  597 
Spina  ventosa,  472 
Spinal,  curvatures,  479,  507 

hemorrhage,  655 

meningitis,  655 

paralysis,  627 

tumors,  662 
Spirochetosis,  404 
Spleen,  diseases  of,  556 

movable,  wandering,  556 

normal,  149 
Splenic,  anemia,  549 

congestion,   557 

leukemia,  550 
Splenitis,  557 

Splenomegaly,   in   pseudoleukemia   infan- 
tum, 549 

primary,  family  TGaucher  type)  558 

semeiology  of,  152 
Spondylitis.  462 

differentiated   from   cervical   rib,   464 
from  rheumatism,  416 
Sponging,  cold  and  hot,  in  hyperpyrexia, 

89 
Spotted  fever   {see  Typhus),  404,  410 
Sprue,  233 

Sputum,  semeiology  of,  138 
Starting  pain,  in  coxitis,  469 

in  spondylitis,  463 
Static   current,  96 
Status  idioticus,  702 
Status  lymphaticus,  568 
Sterilization  of  milk,  51 
Sternocleidomastoid,  hematoma  of,  208 


796 


INDEX 


Stenunn,  dofects  of,  181 
Stiffness  of  neck  {see  Rigidity),  129,  607 
Stigmata  of  degeneration,  697 
Still's  disease,   422 
Stimulants,   108 
Stomacace,  234 
Stomach,  scmciology  of,  147 
capacity  of,  in  infants,  55 
Avasliing  of,  93 
Stomatitis,  233 

treatment  of,  230 
Stones  in  bladder,  580 

in  kidneys,  578 
Stools,  fat  in,  38 

semeiology  of,  158 
Strabismus,  semeiology   of,   120 
Strangulation,    intestinal,     differentiated 
from    acute    appendicitis,    peri- 
tonitis and  intussusception,  207 
Strawberry  tongue,  in  scarlatina,  384 
Stridor  congenitus,  180 
Struma,  501 
Strumitis,  501 
Strumous   ophthalmia    {see   Scrofulosis), 

459 
Stuttering,  as  a  result  of  adenoids,  299 
St.  Vitus'  dance,  378 
Sugar-cake   or   coated  liver    (Pick's   dis- 
ease), 285 
Sugar,  assimilation  of,  30 

faulty,  55 
Sugar-loaf-shape  of  skull    (Oxycephaly), 

708 
Sulphur,  baths,  91 
fumigation,  71 
Summer   complaint    {sec   Cholera    Infan- 
tum), 250 
Suprarenal  extract,  113 

in  asthma,  339 
Surgical  treatment  of  amentia,  749 
Sweating,  excessive  in,  German  measles, 
304 
rickets,  500 
Sydenham's  chorea,  078 
Syphilis,  acquired,  494 
congenital,  482 

differentiated  from  hydrocephalus,  712 
from  rachitis,  510 
from  scrofulosis,  400 
embryonalis  s.  fetalis,  482 
hereditary,  482 

late,  490 
neonatorum,  483 
triad  of  syphilis,  490 
treatment,  495 
Wassermann  reaction  in,  85 
Syphilitic    arthritis,    differentiated    from 
rheumatic,  418,  421 
dactylitis,     differentiated    from    spina 
ventosa,  472 


Syphilitic— Cont  'd 

laryngitis    differentiated    from    simple 
and  tuberculous   laryngitis,   312 
Syringomyelia,  054 

T 

Tabardillo   {see  Typhus  Fever),  404 
Tabes  mesenterica,  450 
Taches  cerebrales,  008 
Taenia?  {sec  Tenia?),  278 
Talipes,  202 

paralytic,  017,  044 
Tapeworms,  278 

Taste,  abnormal  sense  of,  in  amentia,  701 
Tay-Sachs'  disease  {see  Amaurotic  Fam- 
ily Idiocy),  710 
Teeth,  Hutchinson's  in   syphilis,  490 

permanent,  124 

semeiology  of,  120 

temporary,  124 
Teething,  abnormal,  125 

difficult,    230 

normal,  124 
Telangiectasis,  777 
Tendon  reflexes,  171 
Teniae,  278 
Tepid  baths,  90 

Testicles,    congenital    malformations    of, 
193 

undescended,  195 
Tests  for,  acetone  and  diacetic  acid,  524 

allergy,  87 

hearing,  300 

mental,   Schick's,   74,   705,   753 

tuberculin,   82 

Wassermann-Noguchi,  85 

Widal,   80 
Tetanism,  071 

differentiated  from  eclampsia,  tetanus 
and  tetany,  072 

resembling  tetanus  neonatorum,  227 
Tetanus,  antitoxin,  77,  227 

neonatorum,  227 
Tetany,   073 

electricity  in,   98 
Therapeutics,  88,  101 
Thigh   friction,  593 
Thiosiamine,    in    stenosis    of    esophagus, 

240 
Thomson's    disease    {see    Myotonia    Con- 
genita), 205 
Thoracoabdominopagtis,   189 
Thorax,  activity  of,  133 

diagnostic  lines  of,  135 

pain  on  pressure  of,  133 

shape  of,  132 

tumefactions   of,   133 
Threadworms    {see    Oxvuris   Vermicular,- 

is),  270 
Throat,  diseases  of,  288 
Thrombosis,  sinus,  004 


INDEX 


797 


Thrush,   233 
Thjniitis,  acute,  566 

chronic,  563 
Thymol,  specific  in   uncinariasis,   282 
Thymus,   asthma,  568 

death,   568 

gland,  diseases  of,  564 

gland  extract,   113,  747 
Thyroid  gland,   diseases  of,  129,   561 

extract,  113,  746 
Tic  (spasm),  681 
Tie  fever,  410 
Tinea  favosa,  776 

kerion,  775 

trichophvtina,  capitis  and  corporis,  774, 
776 
Tongue,  diseases  of,  238 

scrotal  in  Mongolism,  719 

semeiology  of,  127 

tie,  177 
Tonics,  103 
Tonsillectomy,   296 

dangers  of,  297,  300 
Tonsillitis,   293 

differential  diagnosis  of,  294 
Tonsillotomy,   296 
Tonsils,  hypertrophy  of,   296 

removal  of,  296 

semeiology  of,  128 
Top-milk,  49 

Torsion,  spasm,  progressive,  688 
Torticollis,  electricity  in,  99 

in  retropharyngeal  abscess,  302 

in  rheumatism,  416 

tonsillitis,  294 
Touch,  pain  and  temperature  senses;  ab- 
normal in  amentia,  702 
Toxin-antitoxin    immunization    in    diph- 
theria,  75,  370 
Trachea,    congenital    malformations    of, 

180 
Tracheobronchitis,  314 
Tracheocele,   180 
Tracheotomy  in  diphtheria,  381 
Triad,  anticostive,  263 

of  syphilis,  490 

of  tetany,  673 
Trichiniasis    {see  Polymyositis),   425 
Tricuspid  valve,  disease  of,  540 
Trident  hand,  514,  722 
Trismus  neonatorum,   226 
Trousseau 's  sign,  in  meningitis,  608 

in  tetany,  673 
Tuberculin,  tests,  82 

therapy,  83 
Tuberculosis,  437 

abdominal  organs,  453 

bones  and  joints,  461 

brain,  452 

bronchial  glands,  444 

complement-fixation  reaction  in,  84 


Tuberculosis — Cont  'd 

genitourinary   tract,   456 

intestines,  456 

lungs,  442,  444 

knee  joint,  470 

lymphatic  glands,  458 

meningitis,   599 

metacarpals  and  phalanges,  472 

miliary,  442 

peritoneum,  453 

prevention  of,  437 

skin  and  glands,  458 

vertebral  column,  462 
Tuberculous  arthritis,  differentiated  from 
rheumatic,  421 

coxitis,  470 

dactylitis,    from   syphilitic,   472 

meningitis,    from    nontuberculous,    614 

peritonitis,     from     similar     affections, 
154 
Tumors  of,  brain,  645 

bones,  476 

cord,  662 

kidneys,  582 

larynx,   313 

liver,  286 

nose,   290 

phantom,  hysterical,   684 

sacrum  and  coccyx,  200 
Tussis,       convulsiva,       {see       Whooping 
Cough),  429 

in  the  newborn,  434 
Typhlitis,  269 
Typhoid  fever,  399 

differentiated  from  gastroenteritis,  in- 
fluenza, malaria,  meningitis, 
pneumonia,  Eocky  Mountain 
fever,  tuberculosis,  typhus  fever, 
402 

Widal  reaction  in,  86 
Typhoid  spine,  401 

Typhus  exanthematicus  or  spotted  fever, 
404 

Weil-Felix  reaction  in,  86 

IT 

Umbilical,  arteritis  and  phlebitis,  228 

granuloma,   222 

hemorrhage,  222 

hernia,  197 
Umbilicus,  diseases  of,  219 

care  of,  221 
Uncinariasis,  281 

Undescended   testicles    {see   Cryptorchid- 
ism),  195 
Urachus,  fistula,  191 

persistence  of,  191 
Uranocoloboma,  176 
Uranoschisma,  176 
Uremia,  575 


(98 


INDEX 


Uremia — Cont  M 

fliflPorontiated  from  meningitis,  613 

scarlatinal,  088 

treatment  by  lumbar  puncture,  577 
Ureters,  congenital  malformation  of,  192 
Urethra,  congenital  malformation  of,  193 
Uric  acid,  infarct,  231 

in  urine,  162 
Urinary  findings,  patliologic,  159,  574 
Urticaria,  764 
Uvula,  semeiology  of,  128 


Vaccination,  72 

contraindications  to,  74 

re  vaccination,  73 
Vaccines,  bacterial,  81 

in  bubonic  plague,  500 

in  influenza,  354 
Vaccinia,  93 

Vagina,  congenital  malformations  of,  197 
Vaginal  discharge,   164,  589 
Vaginitis,  589 
Valvular  heart  disease,  536 
Vapor  pack,  89 
Varicella,  395 
Variola,   395 

differential   diagnosis,    398 

vaccine,  72 
Varioloid,   396,   397 
Ventilation,   66 

Ventricles,  communication  of,  527 
Vertebral   column,   congenital   malforma- 
tions of,  165 

disease    of,    tuberculous,    462 

tumors  of,  166 
Vesical  calculi,    {see  Bladder  Diseases), 

586 
Vincent's  angina,  294 
Vision  disturbances,  semeiologv  of,  121, 

701 
Vitellointestinal  duct,  190 
Vitamines,   114,  504,  514,   517 
Vitia  cordis,  214 

acquired,  529 

congenital,  525 


Vocal  resonance,  semeiology  of,  137 
Vomiting,  cyclic,  periodic,  recuiront,  522 

semeiology  of,  156 
Vomitus,  semeiology  of,  156 
Von  Jakseh's  anemia,  549 
Von  Pirquet  tuberculin  test,   82,  438 
Vulva,  atresia,  of,   197 
Vulvovaginal    discharge,    semeiology    of, 

164 
Vulvovaginitis,  catarrhal,  parasitic  (gon- 

norrheal)  and  traumatic,  589 
treatment  of,  593 

W 

Warm  baths,  90 

Wassermann  reaction  in  syphilis,  85 

Weakness    of    extremities    and    muscles, 

semeiology  of,  167 
Weaning  of  baby,  59 
Weight  chart,  171 
Weil's    disease    {see    Epidemic    Icterus), 

283 
Werlhoff's  disease   {see  Purpura  Hemor- 
rhagica), 554 
Wet  nursing,  46 

contraindications  to,  47 
Whey,  57 

White  swelling,  469,  470 
Whooping  cough,  429 

in  the  newly  born,  434 
Widal's  i-eaction  in  typhoid,  86 
Winckel's  disease  {see  Hemoglobinuria), 

229 
Wolff-Eisner,  tuberculin  test,   82 
Woman's  milk,  composition  of,  48 

feeding,  42 

testing   of,   45 
Worms,  intestinal,  276 


Yaws   {see  Frambesia),  496 
Yeast,   autolized   in   Beriberi,   517 
Yellow  atrophy  of  liver,  acute,  285 
Yellow  fever,  411 

prophylactic  inoculatior  in,  412 


Date  Due 

■ 

PRINTED  IN  U.S.A.            CAT.   NO.   24    ]61               m 

A  000  432  614  6 


WS200 

S5i*2d 

1921 

Sheffield, 

Herman  B 

Diseases 

of 

children 

... 

WS200 
S5^2d 
1921 
Sheffield,  Herman  B 

Diseases  of  children  . . . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE.  CALIFORNIA  92864 


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